Postoperative management in adults
A practical guide to postoperative care for clinical staff
1 2 3 4 5 6 7 8 9
Introduction Clinical assessment and monitoring Cardiovascular management Respiratory management Fluid, electrolyte and renal management Management of sepsis Postoperative nutrition Information for discussion with patients and carers Development of the guideline
1 3 11 20 28 34 39 44 45 48 49 52
Abbreviations Annexes References
COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE BY CALLING 0131 247 3664 OR ONLINE AT WWW.SIGN.AC.UK
KEY TO CONSENSUS AND EVIDENCE STATEMENTS
CONSENSUS STATEMENTS CS Statements developed from structured discussion, informed by any existing evidence and the group’s clinical experience, and validated using a formal scoring system.
LEVELS OF EVIDENCE 1++ 1+ 12
High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal Non-analytic studies, eg case reports, case series Expert opinion
2+ 23 4
GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++ and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+
THE NEED FOR GUIDANCE
Over the past five years, annual reports from the Scottish Audit of Surgical Mortality (SASM) have highlighted problems in perioperative management of patients. These include failure to predict or recognise clinical decline, failure to involve consultants at an early stage and failure to appreciate the consequences of not acting promptly when decline is identified.1 SASM has consistently highlighted variation in practice in postoperative care. Almost 2,000 patients die following surgery in Scotland each year. In the vast majority, death is the inevitable consequence of the disease process. However, it is likely that some 10,000 patients per year suffer major complications after surgery and best practice guidelines might have an impact in this area. As a consequence of these audits, SASM has called for the development of local and national guidelines on the use of intensive care unit (ICU) and high dependency unit (HDU) resources and in particular has suggested that the Scottish Intercollegiate Guidelines Network (SIGN) should produce guidelines for postoperative management focusing on symptoms and signs of wellknown serious complications. The target audience for the guidelines would be nursing, allied health care and trainee medical staff. It was suggested that a SIGN guideline could cover monitoring of postoperative patients and the investigation and management of clinical deterioration in the postoperative period.
DEVELOPING A CONSENSUS GUIDELINE
The evidence of variation in practice and the repeated calls for guidance in this area clearly indicated the need for a guideline. SIGN however, has always developed evidence based guidelines, and the lack of a strong evidence base of effective practice meant that postoperative management would not be suitable for guideline development using standard SIGN methodology. Instead, it was proposed to develop a guideline using consensus techniques. 2-6 Initial systematic searches were used to identify any relevant evidence and this was critically appraised using standard SIGN methodology. The evidence base was not extensive and was often confined to specific patient groups. The evidence that was appraised was used, together with the clinical experience of the guideline development group, to inform the formal consensus methods that were used to develop recommendations. These are presented in the form of consensus statements. More details of the methodology are given in section 9.
REMIT OF THE GUIDELINE
The remit of the guideline was determined by the guideline development group, who used formal consensus techniques to prioritise their answers to the question What treatment decisions and evaluation criteria do you think are important in postoperative care? This guideline covers: 1. Early identification of at-risk patients 2. Monitoring in the postoperative period 3. Early recognition, investigation, and management of clinical deterioration 4. Identification of key physiological requirements in the postoperative period 5. Referral to expert care 6. Nutrition in the postoperative period.
POSTOPERATIVE MANAGEMENT IN ADULTS
This guideline does not focus on postoperative pain management (an evidence based guideline already exists in this area),7 indications for blood transfusion, the prophylaxis of surgical site infection or venous thrombosis, nor the management of obstetric patients or pregnant women or those patients with head injury or hip fracture (these are covered by separate SIGN guidelines, see www.sign.ac.uk). The guideline excludes the management of children (<18 years of age). The guideline is designed to be used principally by doctors, nurses, paramedical staff and students. It can also serve as a teaching resource.
ETHOS OF THE GUIDELINE
A TEAM APPROACH In 1974 Professor P F Jones dedicated his book Emergency Abdominal Surgery8 to: The Night Watch - my registrar colleagues over the years in recognition of their hard won skills and judgement, their concern for their patients and their continued dedication to emergency care. Then, as now, registrars were supported by teams of junior doctors, nurses and paramedical staff. Much has changed over the years but the basic concept of a team approach to patient care remains. Each member of the team has a role to play in the normal process of recovery from surgery and the early identification and treatment of any deterioration in the condition of the patient. This guideline complements the team approach by concentrating on the fundamentals of good patient care and encouraging a simple, didactic and consistent approach. The guideline is not intended to supplant specialist medical care but to help inexperienced clinicians differentiate between those patients who are recovering normally and those in whom there is cause for concern. The distinction between the two is often difficult and the guideline emphasises early referral for senior or specialist advice where there is any doubt.
FOCUSING ON POSTOPERATIVE MANAGEMENT The guideline concentrates on the postoperative period and does not address concepts such as optimisation or protective strategies instituted preoperatively. The development group recognises that the postoperative period is only one part of the journey of care but, as reported by SASM, this is perceived to be an area where the need for guidance is paramount.1 Much has been said about the Golden Hour after trauma when decisions taken can have a significant effect on outcome. There may well be a Platinum 24 Hours after surgery when patients are particularly vulnerable and where decision making has similar importance. This guideline is designed to assist trainee staff in making decisions even if that decision is to call for advice. The guideline development group recommends that surgical units develop protocols that make it clear when it is time to call for advice.
STATEMENT OF INTENT
This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the appropriate healthcare professional(s) in light of the clinical data presented by the patient and the diagnostic and treatment options available. It is advised however that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patients case notes at the time the relevant decision is taken.
2 CLINICAL ASSESSMENT AND MONITORING
Clinical assessment and monitoring
Optimal management of patients throughout the postoperative phase requires appropriate clinical assessment and monitoring. In contrast with assessment of emergencies, which focuses on the initial diagnosis and stabilisation after the patient has developed a complaint, postoperative care requires pre-emptive management. Regular assessment, selective monitoring and timely documentation are key to postoperative care. This section of the guideline describes a model of care that establishes a minimum standard of practice in postoperative patient care.
DISCHARGE FROM POSTANAESTHETIC RECOVERY The following criteria must be fulfilled before a patient can be discharged from the recovery room:9
the patient is fully conscious, responding to voice or light touch, able to maintain a clear airway and has a normal cough reflex respiration and oxygen saturation are satisfactory (10-20 breaths per minute and SpO2>92%) the cardiovascular system is stable with no unexplained cardiac irregularity or persistent bleeding. The patients pulse and blood pressure should approximate to normal preoperative values or should be at a level commensurate with the planned postoperative care pain and emesis should be controlled and suitable analgesic and anti-emetic regimens should be prescribed temperature should be within acceptable limits (>36°C) oxygen and fluid therapy should be prescribed when required.
Prior to discharge, recovery staff should record in the notes that patients have met these criteria. If the patient does not achieve these criteria they should be assessed by the anaesthetist responsible for either the procedure or postanaesthetic recovery with a view to upgrade to level 2 or 3 care (see section 2.1.2). CS Anaesthetic and surgical staff should record the following items in the patients case notes: n any anaesthetic, surgical or intraoperative complications n any specific postoperative instruction concerning possible problems n any specific treatment or prophylaxis required (eg fluids, nutrition, antibiotics, analgesia, anti-emetics, thromboprophylaxis).
POSTOPERATIVE MANAGEMENT IN ADULTS
LEVELS OF CARE Postoperative care is provided in several different locations depending on the level of monitoring or organ support that is required. At any time it may become appropriate to move a patient to a setting in which a different level of care can be provided. The review of adult critical care services10 recommends that the existing classification of ward, HDU and ICU, be replaced by a classification of care that focuses on the level of care required by the patient, regardless of location. The following definitions of care have been used throughout this guideline: Level 0 - formerly ward Appropriate for patients
who have had minor surgery whose needs can be met through normal ward care
Level 1 - formerly ward Appropriate for patients
n n n
at risk of their condition deteriorating recently relocated from immediate postanaesthetic recovery whose needs can be met on a surgical ward with additional advice and support from a critical care team
Level 2 formerly HDU Appropriate for patients
requiring more detailed observation or intervention including support for a single failing organ system stepping down from a higher level of care
Level 3 - formerly ICU Appropriate for patients
n n n
requiring advanced respiratory support alone requiring basic respiratory support together with support of at least two organ systems requiring complex support for multi-organ failure.
THE FIRST POSTOPERATIVE ASSESSMENT WHEN AND WHO? The first postoperative assessment should take place immediately after surgery on return to the ward. It provides a baseline against which the patients condition may subsequently be assessed and identifies any problems that may have occurred on transfer from the operating department. CS A postoperative assessment should be carried out when the patient returns from theatre.
This assessment may be carried out by the doctor responsible in the first instance for patient care, usually the House Officer. When the doctor is unavailable or the case is minor and straightforward a trained nurse could complete this assessment. The doctor should attend later to assess the patient in person. Any departure from accepted physiological parameters (see sections 3-6) requires the attendance of the doctor as a matter of urgency. CS Doctors immediately responsible for patients should ensure that a contact/pager number is available to the nursing staff on the ward.
2 CLINICAL ASSESSMENT AND MONITORING
THE FIRST POSTOPERATIVE ASSESSMENT HOW? The first assessment reviews the intraoperative course, past medical history, medications and allergies. The nurse responsible for the care of the patient should inform the doctor of any other information concerning deterioration or incident during the patients transit from theatre. CS If the nurse responsible for the care of the patient becomes unavailable for discussions with other members of the care team, they should pass on all pertinent information to another member of nursing staff who then assumes responsibility for that patient.
A structured care plan may aid the exchange of information between healthcare professionals. Physical examination of the patient is different from the routine examination of patients preoperatively. In the routine situation, the doctor has time to carry out a structured examination which includes the variables described below. In the emergency setting, the standard airways, breathing and circulation or ABC approach would be followed. The focus, in postoperative assessment, is on circulatory volume status, respiratory function and level of consciousness. Table 1 shows a checklist for the first postoperative assessment. CS The first postoperative assessment should determine: n intraoperative history and postoperative instructions n circulatory volume status n respiratory status n mental status.
The conscious level is often difficult to assess. The AVPU (Fully Alert, responsive to Verbal or Pain, or Unresponsive) examination is a simple screening test and has been widely used in emergency patient management. The abbreviated mental test (AMT), using 10 key questions, is useful in acutely confused postoperative patients.11,12 The Glasgow Coma Scale (GCS) is rather insensitive for confused patients, however, GCS 12 or less constitutes a medical emergency and should be discussed with senior doctors prior to management at level 2 or 3 (see Annex 1 for details of these scales). Common causes of postoperative confusion include:
n n n n n n n n n n
sepsis (eg infection of chest, urinary tract, wound, intravenous cannula site, or intra-abdominal collection) sedative drugs hypoxaemia hypercarbia hypoglycaemia acute neurological event myocardial infarction urinary retention alcohol/drug withdrawal hepatic encephalopathy biochemical abnormality (eg urea, sodium, potassium, calcium, thyroid function, liver function). CS If an acute confusional state is present, exclude treatable causes by appropriate history, physical examination and investigations.
Having assessed the patient, the doctor should legibly record the findings in the notes at the same time. Any specific problems should be recorded and a management plan developed. The interval after which the patient should be reassessed should also be chosen at this stage.
POSTOPERATIVE MANAGEMENT IN ADULTS
Table 1: The first postoperative assessment Checklist for the first postoperative assessment Review intraoperative history and postoperative instructions
n n n n n n
past medical history medications allergies intraoperative complications postoperative instructions recommended treatment and prophylaxis. oxygen saturation effort of breathing/use of accessory muscles respiratory rate trachea - central or not? symmetry of respiration/expansion breath sounds percussion note. hands - warm or cool, pink or pale capillary return less than two seconds or not? pulse rate pulse volume pulse rhythm blood pressure (see section 3.3) conjunctival pallor jugular venous pressure (JVP, see below) urine colour and rate of production (see section 5.6) drainage from drains, wounds and nasogastric tubes. Patient conscious and normally responsive (AVPU) n If abnormal determine whether confusion is present (AMT) n If abnormal determine GCS, oxygen saturation and blood glucose. any significant symptoms, such as chest pain or breathlessness pain and adequacy of pain control.
Complete a respiratory status assessment
n n n n n n n
Complete a circulatory volume status assessment
n n n n n n n n n n
Complete a mental status assessment
In addition to the physical assessment, record:
Following specialist surgery it may be necessary to assess additional factors.
Appropriate lighting should be used in order to visualise the jugular venous pressure. The height of the JVP should specify the marker used; clavicle, sternal angle etc. 13 Proformas, which provide tick boxes to speed the recording of information after the postoperative assessment, may be useful.
2 CLINICAL ASSESSMENT AND MONITORING
ADDITIONAL ASSESSMENTS The initial postoperative assessment will determine how frequently reassessment of the patient is required. Patients who display any abnormal physiological variables, in addition to severe pain, must be reassessed more frequently than patients who are stable and comfortable. Surgery out-of-hours in patients who are American Society of Anesthesiologists (ASA) physical status grade ≥3 (see Annex 2) has been shown to be an independent risk factor for postoperative emergencies requiring intensive care team attendance. Thirty per cent of these emergencies occur within the first six postoperative hours.14 CS CS Patients at risk of deterioration require frequent assessment. Patients with the following risk factors for deterioration should be reassessed within two hours of the first postoperative assessment: n ASA grade ³3 n emergency or high risk surgery n operation out of hours.
TREATMENT AND PROPHYLAXIS
The following postoperative treatment and prophylaxis options should be discussed preoperatively with the appropriate members of the clinical team:
n n n n
n n n n
adequate pain control venous thromboembolism prophylaxis antibiotic prophylaxis continuation of current medications (these, and in particular cardiorespiratory treatments, should be continued wherever possible) substitution of current medication (eg diabetic control, steroid therapy) prophylaxis for postoperative nausea and vomiting ability of patients to take drugs by mouth pressure area management. physiotherapy nutrition team consultation (see section 7.5.4) oral hygiene. Local protocols should be established for: n drug treatment of pre-existing cardiovascular and respiratory disorders n treatment of postoperative nausea and vomiting.
Postoperatively, consider the need for:
n n n
In patients with persistent vomiting, exclude gastrointestinal obstruction before providing drug treatment for vomiting.
POSTOPERATIVE MANAGEMENT IN ADULTS
ROUTINE MONITORING Monitoring allows the collection of routine data so that trends may be established, assisting in the detection of deterioration or improvement. This is vital for an objective assessment of a patients response to treatment. In general, the anaesthetist will recommend a monitoring regimen for the first few hours after surgery, which would normally include:
n n n n n n n
temperature pulse rate blood pressure respiratory rate pain assessment (resting and moving) urine output (postoperative voiding) peripheral oxygen saturation.
Experienced nurses will usually institute an appropriate regimen after this initial period, depending on local practice. If any problems are encountered, the frequency of monitoring may be increased. Monitoring will be most frequent initially (eg every 15 minutes for the first hour), becoming less frequent over time (eg every 30 minutes for the next two hours, and hourly for a period thereafter). The frequency and exact content of the assessment should be tailored to the individual patient and not all parameters will need to be measured at all time points. Excess data collection in well patients is confusing, time consuming and may prevent patients sleeping properly. Conversely, lack of monitoring in patients who may deteriorate can lead to late detection of serious problems. CS The doctor completing the initial postoperative assessment should consider the monitoring regimen and appropriate level of care required for the next 24 hours in collaboration with the nursing team. Documenting numerical data in graphical form facilitates the assessment of trends. (see example in Annex 3)
NB The monitoring of nutritional status and support is discussed in section 7.5.3. 2.4.2 ADDITIONAL MONITORING Patients with, for example, pre-existing cardiorespiratory disease or who have had longer, more physiologically stressful operations may need additional, more frequent or continuous monitoring (see Table 2). These patients may require a setting other than the routine ward for a higher level of care. Table 2: Suggested additional monitoring Additional monitoring requirements dependent on clinical status ECG Hourly urine volumes Arterial blood pressure Central venous pressure Arterial blood gases Drainage from wounds Haematology Biochemistry
2 CLINICAL ASSESSMENT AND MONITORING
Continuous oxygen saturation and electrocardiography (ECG) may be carried out by automatic equipment. Patients requiring advanced monitoring or frequent detailed assessments may be more appropriately cared for in a level 2 setting.15 CS CS Patients requiring the frequent monitoring of multiple variables should be considered for care at level 2 or above. n Any patient with circulatory disturbance should be catheterised and the urine output measured hourly n Consider catheterisation in patients with no urine production after four hours.
Patients with complex needs often require enhanced levels of care. Invasive cardiovascular monitoring, including the use of indwelling central venous or arterial cannulae, is usually restricted to level 2 or level 3 care. Patients who are initially admitted to the postoperative ward or to areas providing level 1 or 2 care may require a higher level of care thereafter. Patients who show cardiovascular instability or respiratory difficulty should be considered very early in the postoperative course to be candidates for level 2 or 3 care. 2.4.3 RULES AND TRIGGERS FOR MONITORING AND INTERVENTION Patient monitoring is most useful when the doctor and nurse responsible for care agree:
specific criteria that should prompt a call to the doctor specific time points (eg half hourly, hourly) for the reporting of trends, whether or not the parameters being monitored fall within abnormal levels. Trends in the physiological data, rather than absolute numbers, should be reported to assist in the detection of deteriorating patients before a severe physiological compromise occurs.
DAILY CLINICAL ASSESSMENT
Successful management of patients in the postoperative period requires routine assessment until discharge. Repeated clinical assessment is key to early detection of deterioration but, depending on the clinical condition of the patient, does not need to be as detailed as the initial assessment. Surgical patients are usually seen once or twice a day on the ward round and their status must be documented. Clear clinical notes must be kept and an entry made every time a patient is reviewed. This assessment is the most complete opportunity to ensure that the patient is progressing in a satisfactory manner. Each daily assessment is an opportunity to modify the monitoring regimen so as best to provide data for clinical decision making. CS
Postoperative monitoring should be continued on a daily basis The monitoring regimen should be reviewed daily so as best to provide data for clinical decision making Any change in a monitoring regimen should prompt reassessment of the level of care.
POSTOPERATIVE MANAGEMENT IN ADULTS
THE ROLE OF SENIOR MEDICAL STAFF
Where junior doctors have difficulty managing a patient, or in admitting a patient to a special care area, it is essential to discuss the patient with the responsible senior doctors. Training in postoperative care may influence outcome.9 CS
The ultimate responsibility for patient care lies with the consultants providing surgical and anaesthetic care Junior doctors should assume only the responsibility appropriate to their training and experience Where a junior doctor feels that they may exceed their personal responsibilities or capabilities, they have a duty of care to discuss the patient with a more senior doctor in the same clinical team.
3 CARDIOVASCULAR MANAGEMENT
In general, maintaining a patients heart rate and blood pressure within normal limits will result in a satisfactory outcome. However, there are no clinical studies to indicate what is normal with respect to heart rate and blood pressure for individual patients in the postoperative period. Surgery is associated with a stress response that persists postoperatively.16 Anaesthesia modifies the stress response, which can be further modified by the use of techniques such as regional anaesthesia or use of high dose opioids. During anaesthesia heart rate and blood pressure are maintained within appropriate limits at the discretion of the anaesthetist. On emergence from anaesthesia this damping down of the stress response is lost and heart rate and blood pressure rise in the postoperative period.
Most patients will tolerate a postoperative heart rate of between 50 and 100 beats per minute. A heart rate outside these limits may indicate that all is not well with the patient.
BRADYCARDIA A heart rate below 50 beats per minute may be normal in a patient who is otherwise well. If the blood pressure is well maintained, the simplest strategy is to observe the patient closely over the next few hours. In some patients a slow heart rate can reduce blood pressure as a result of reduced cardiac output (cardiac output = heart rate x stroke volume). Correcting the slow heart rate with a vagolytic agent (eg intravenous glycopyrronium bromide 0.2-0.4 mg or atropine sulphate 0.3- 0.6 mg) should restore the blood pressure and allow time for the cause of the low blood pressure and heart rate to be deduced. If the blood pressure does not respond to the increase in heart rate then other possible causes should be considered, such as blood loss (see Table 4).
TACHYCARDIA Heart rates over 100 beats per minute may be well tolerated by fit patients but may indicate a clinical problem. Sustained tachycardia is particularly dangerous for patients who have documented ischaemic heart disease or risk factors for ischaemic heart disease as myocardial oxygen supply cannot be increased (see section 3.4). Tachycardia associated with high blood pressure may simply be the consequence of pain and anxiety and appropriate analgesia may be all that is required. If elevated rates and pressure are maintained despite good analgesia, senior advice should be sought. In hypovolaemic patients tachycardia may precede development of hypotension. Hypotension indicates severe hypovolaemia caused by fluid deficit and in the context of recovery from surgery, acute blood loss should be excluded. Assessment of fluid balance is mandatory at this stage (see section 5).
The Sixth Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure gives a classification of blood pressure.17 Note that this is a general classification and is not specific to patients undergoing surgery (see Table 3).
The American College of Cardiology/American Heart Association (ACC / AHA) guidelines18 recommend deferring surgery if the diastolic pressure is above 110 mm Hg and systolic is above 180 mm Hg. Antihypertensive medication should be continued during the postoperative period for patients with known and treated hypertension, as unplanned withdrawal of treatment can result in rebound hypertension. In practice, the decision to give antihypertensive drugs must be made for each patient, taking into account their normal blood pressure, and their postoperative blood pressure. For some patients, after major surgery, this may require a change from oral to parenteral administration. The advice of the clinical pharmacist should be sought about equivalent dosages or suitable alternatives to oral preparations. Many patients on admission to hospital have elevated systolic pressure with normal diastolic pressure. Once settled into the ward environment systolic pressure often falls to normal. Around half of those aged over 60 years have isolated systolic hypertension.19 A linear relationship exists between increasing admission systolic pressure and the risk of postoperative silent ischaemia. 20 A clear association between admission arterial pressure and major perioperative cardiac complications has not however been demonstrated.21,22 CS Postoperative blood pressure should always be reviewed with reference to the preoperative and intraoperative assessments.
HYPOTENSION Hypotension is defined as either a systolic blood pressure of less than 100 mm Hg or as a fall of at least 25% from the patients normal pressure. Hypotension is relatively common postoperatively and may be drug induced (eg residual effects of anaesthesia, epidural or opioids) or may represent fluid deficit. Table 4 lists broad categories for the assessment of hypotension. Hypotension should not be allowed to persist unless the clinician is absolutely sure that no important pathological process is taking place. If in doubt senior advice should be sought. CS Further assessment is required for patients with: n heart rate below 50 beats per minute n heart rate above 100 beats per minute n blood pressure below 100 mm Hg systolic.
3 CARDIOVASCULAR MANAGEMENT
Table 4: Assessment of hypotension Assessment of hypotension Observe if:
Awake or easily rousable Comfortable Normal preoperative BP Warm Well perfused (capillary refill <2 seconds) Heart rate 50-100bpm Passing urine (>0.5 ml/kg/hr) No obvious bleeding
Seek further advice if:
Drowsy or unrousable Distressed Hypertensive preoperatively Cold Capillary refill >2 seconds Heart rate >100 or <50 bpm Oliguric (<0.5 ml/kg/hr) Signs of bleeding (drains, wounds, haematoma)
HYPERTENSION Hypertension is common in the postoperative period as a result of a number of factors including the stress response, pain, anxiety and failure to continue medication perioperatively. Postoperative hypertension is associated with bleeding, cerebral events and myocardial ischaemia especially if the heart rate is also elevated. Treatment of Hypertension Beta blockers and intravenous (IV) nitrates are effective for the control of postoperative hypertension.23,24 CS CS If patients are hypertensive, ensure that they are receiving adequate analgesia. If hypertension persists seek specialist medical advice and review the level of care. Patients on regular antihypertensive medication should normally be maintained on this medication perioperatively. If the patient becomes hypotensive then it may be appropriate to discontinue some drugs. Beta blockers and IV nitrates may be used safely and effectively in postoperative hypertension.
Patients with ischaemic heart disease or risk factors for ischaemic heart disease represent a special group in whom the maintenance of heart rate and blood pressure within normal limits may not prevent perioperative myocardial ischaemia (MI). They do not always increase myocardial oxygen supply to match an increased myocardial oxygen demand. An estimated 30% of patients undergoing surgery in the United States have ischaemic heart disease or risk factors for ischaemia.25 It is reasonable to assume that the population is similar in Scotland.
MYOCARDIAL ISCHAEMIA IN THE POSTOPERATIVE PERIOD Myocardial ischaemia in the first 48 hours after an operation is the single most important predictor of serious cardiac events (including cardiac death, myocardial infarction, unstable angina, congestive heart failure and serious arrhythmias).26-28 Ischaemia is common, occurring in up to 48% of those at risk (see Tables 5 and 6).29,30 It is most likely to be silent although there may be an association with elevated heart rates.26,27 Ischaemia which persists for over two hours is likely to result in a significant cardiac event.31-34
POSTOPERATIVE MANAGEMENT IN ADULTS
Factors affecting supply and demand of myocardial oxygen include:
n n n n n n n n n n n
release of pro-inflammatory mediators hypercoagubility diminished fibrinolytic activity endothelial dysfunction atherosclerotic plaque instability fluctuating adrenergic activity plasma catecholamine levels body temperature pulmonary dysfunction fluid balance pain.
It used to be considered that the peak incidence for perioperative myocardial infarction was the third postoperative day. Recent studies using biochemical markers and serial ECGs suggest that infarction occurs earlier, either on the day of surgery or during the first postoperative day. 35 Most infarctions are non-Q wave in nature suggesting the cause is prolonged ischaemia rather than rupture of an atheromatous plaque. However, one small study in patients who died following perioperative myocardial infarction described similar pathological features - plaque haemorrhage, rupture and thrombosis, as is seen with non-operative MI.36 In unselected groups of patients undergoing surgery the risk of perioperative infarction is less than 2%. In patients with ischaemic heart disease, undergoing major surgery, the rate is over 5%. Risk is determined both by patient factors and the nature of the surgery, with patients undergoing major vascular surgery facing the highest risks. Despite advances in detection and treatment, mortality after infarction remains high, with rates ranging from 17% to over 50%.37 The long term risk over two years of having an adverse cardiac outcome increases by 2.8 fold (95% CI 1.6-4.9) in patients with postoperative ischaemia and 14 to 24 fold (CI 7.5-53) in patients with postoperative infarction or unstable angina.25,38 For patients who leave hospital alive, event free survival decreases from 93% to 78% when compared with patients with no episodes of myocardial ischaemia.38 All patients who suffer adverse cardiac events should be referred for assessment by cardiologists and consideration of cardiac risk reducing strategies for the longer term. 3.4.2 ASSESSING THE RISK OF POSTOPERATIVE CARDIAC COMPLICATIONS The ACC/AHA guidelines on perioperative cardiovascular evaluation for non-cardiac surgery include a full discussion of preoperative assessment.18 In the perioperative period, the Revised Cardiac Risk Index is a useful tool. It stratifies risk based on the presence of a number of clinical factors, thus informing an appropriate patient management plan (see Tables 5 and 6).18,39 Table 5: Revised Cardiac Risk Index Clinical factors High risk surgery (see Table 6 for definitions) History of ischaemic heart disease History of congestive heart failure History of cerebrovascular disease Preoperative insulin treatment Preoperative creatinine >180 micromol/l. The rates of major cardiac complications postoperatively with 0,1,2,3 or more risk factors were 0.5%, 1.3%, 4% and 9% respectively.
3 CARDIOVASCULAR MANAGEMENT
PROCEDURE-ASSOCIATED RISK Table 6: Surgical procedures stratified by cardiac risk level HIGH RISK PROCEDURES reported cardiac risk >5% Emergency major operations, particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss INTERMEDIATE RISK PROCEDURES reported cardiac risk generally <5% Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopaedic surgery Prostate surgery LOW RISK PROCEDURES reported cardiac risk generally<1% Endoscopic procedures Superficial procedures Cataract surgery Breast surgery Patient and procedure-associated risk factors should be taken into account preoperatively when planning any surgical procedure. Clinicians caring for patients postoperatively need to appreciate the level of risk and any clinical factors which may influence that risk. CS Clinicians caring for patients postoperatively must be aware of clinical factors which increase risk to the patient and how these interact with the risks imposed by the surgical procedure.
MEDICAL TREATMENT TO REDUCE PERIOPERATIVE CARDIAC RISK
Several studies have demonstrated that beta blockers are effective in reducing perioperative ischaemia.40-43 Although caution has been expressed in the general use of prophylactic beta blockade,44 reviews suggest that perioperative blockade reduces the incidence of both ischaemia and MI in patients undergoing high risk surgery.45,46 CS B Clinicians caring for patients postoperatively must be aware of potential optimisation strategies instituted preoperatively that should be continued into the postoperative period. Beta blockers should be continued perioperatively in patients previously taking these drugs for coronary disease, congestive heart failure, hypertension or arrhythmias.
ARRHYTHMIAS AND CONDUCTION DEFECTS
SUPRAVENTRICULAR ARRHYTHMIAS Supraventricular arrhythmias (SVAs) have been reported to occur in 7.6% of patients undergoing major non-cardiac surgery25 and in 10.2% of surgical ICU patients.26 They occur most commonly in the elderly, those with previous cardiorespiratory disease and those undergoing thoracic, vascular or abdominal surgery. The occurrence of SVA is associated with a marked increase in mortality, morbidity and length of stay. SVAs are often a sign of underlying morbidity such as anastomotic leakage and can be regarded as a marker for increased morbidity.
POSTOPERATIVE MANAGEMENT IN ADULTS
VENTRICULAR ARRHYTHMIAS Ventricular arrhythmias occur most commonly in patients with preoperative arrhythmias, smokers and those with a history of heart failure. Non-sustained ventricular arrhythmias do not appear to have prognostic significance and, when occurring without other signs or symptoms of myocardial ischaemia or infarction, may not require aggressive monitoring or treatment during the perioperative period.47
GENERAL MANAGEMENT OF ARRHYTHMIAS
identify and correct underlying factors such as hypoxia, hypovolaemia, electrolyte imbalance and sepsis (see sections 4, 5 and 6) seek expert advice for patients showing cardiovascular instability and review level of care seek expert advice where the diagnosis or management of an arrhythmia is in doubt as DC cardioversion is the first option where tachyarrhythmia results in haemodynamic deterioration A 12 lead ECG should be obtained before and after DC shock or pharmacological cardioversion and a rhythm strip obtained during drug intervention if possible Multiple or inappropriate drug therapy can be dangerous.
MANAGEMENT OF SPECIFIC ARRHYTHMIAS Atrial fibrillation (AF) Chronic - maintain rate control, preferably using the drug treatment found to be effective preoperatively. Oral therapy may need to be converted to parenteral perioperatively. New-onset - may be managed by DC cardioversion, pharmacological conversion to sinus rhythm or rate control. Rate control is indicated where AF has been present for >48hrs, due to the increasing risk of systemic embolus in the non-anticoagulated patient. New-onset AF has a high rate of spontaneous conversion to sinus rhythm (about 50% at 24hrs).48 Pharmacological conversion
amiodarone hydrochloride is well tolerated in ill patients and may be the drug of choice. The standard IV regimen is 300 mg over 1 hour followed by an infusion of 900 mg over the next 24 hours preferably using a central venous catheter. A higher dose regimen such as 125 mg/ hr IV (max 3 g) may achieve higher 24 hour conversion rates.49 This higher dose regimen should only be considered following expert advice. class 1c drugs such as flecainide acetate and propafenone hydrochloride have potentially serious adverse effects and should be avoided, particularly in patients with cardiac disease. IV magnesium sulphate has been reported to be superior to conventional-dose amiodarone hydrochloride in surgical and non-surgical ICU patients and can be considered as an alternative to amiodarone in the critically ill patient.50 The dosing regimen is 8 mmol (2g) intravenously over 10 to 15 minutes repeated once if necessary. A maintenance infusion of 0.1mmol/kg/ hour should only be considered following expert advice. verapamil hydrochloride and diltiazem hydrochloride can effectively control heart rate in patients presenting with fast AF beta blockade with IV esmolol hydrochloride can effectively control heart rate in patients presenting with fast AF verapamil hydrochloride and beta blockers should not be used together because of the risk of severe hypotension and asystole IV digoxin has a relatively slow onset of action and is less effective than other agents uncontrolled studies of acute AF suggest that IV amiodarone hydrochloride may also be effective in controlling the ventricular rate in patients who are critically ill.
Atrial flutter should be managed in a similar manner to atrial fibrillation.
3 CARDIOVASCULAR MANAGEMENT
Supraventricular tachycardia (SVT) Adenosine (3-12 mg) and verapamil hydrochloride (5-10 mg) IV are equally effective in the termination of regular narrow-complex paroxysmal supraventricular tachycardia. Adenosine has the advantage of brief duration of action and less hypotension. It may be associated with a high relapse rate in critically ill patients. Verapamil hydrochloride and beta blockers should not be used concurrently. Ventricular tachycardia (VT) The occurrence of ventricular ectopic beats or non-sustained ventricular tachycardia does not appear to have prognostic significance and, in the absence of signs or symptoms of myocardial ischaemia, may not require aggressive monitoring or treatment. In haemodynamically unstable patients, VT is most effectively treated by DC cardioversion. Inappropriate or ineffective drug treatment may worsen the situation. IV anti-arrhythmic drugs may be used in haemodynamically stable patients. The European Resuscitation Council (ERC) guidelines51 recommend amiodarone hydrochloride or lidocaine hydrochloride as the drugs of choice for monomorphic VT and magnesium sulphate (IV 8 mmol, or 4 ml, 50% over 10-15 min)52 for polymorphic VT. CS CS CS Seek expert help early in the management of serious or potentially serious arrhythmias and reconsider the level of care. The occurrence of supraventricular arrhythmias should provoke a search for underlying causes such as hypoxia, hypovolaemia, electrolyte abnormality, sepsis or drug toxicity. DC shock should be considered as a first treatment option where there is haemodynamic deterioration as a result of a tachyarrhythmia.
Helpful algorithms for the management of acute tachyarrhythmias and bradyarrhythmias can be found in the European Resuscitation Guidelines 2000.51
In general, the indications for pacing in the perioperative situation are no different from those in the nonsurgical context, as stated in the ACC/AHA guidelines53 for implantation of pacemakers and antiarrhythmia devices. CS Seek expert help early when perioperative conduction defects result in bradycardia unresponsive to atropine.
Implanted Pacemakers and defibrillators Patients with implanted pacemakers and defibrillators should have their device checked by a cardiologist before and after surgical procedures.
PERIOPERATIVE MYOCARDIAL INFARCTION
Perioperative MI (PMI) carries a high risk of both short and long term morbidity. It is usually silent in presentation with non-specific ECG changes. Troponin I has been shown to be a sensitive and specific method for the diagnosis of PMI in vascular and spinal surgery patients.54 Troponin T has been shown to be a marker for PMI in patients with CAD or CAD risk factors undergoing non-cardiac surgery.55,56 Serial troponin measurements during the preoperative, intraoperative and postoperative periods may identify myocardial injury, reflect the degree of injury and help in categorising subsequent risk. Patients who sustain perioperative MI should not receive thrombolytic agents. In all other respects they should be managed as in any other setting, receiving aspirin 300 mg orally, but monitored in a setting with immediate specialist input.
POSTOPERATIVE MANAGEMENT IN ADULTS
Where perioperative MI is diagnosed or suspected early specialist medical advice should be sought. Patients with high clinical risk of perioperative MI undergoing high or intermediate-risk procedures should have: n ECG at baseline, immediately following surgery and daily for the two subsequent days n cardiac troponin measurements 24 hours after surgery. In patients without documented coronary disease, surveillance for perioperative MI should be restricted to those who develop cardiac symptoms or signs. Thrombolysis is not indicated in the management of perioperative MI, but all other aspects are as for MI in any other setting.
Patients on warfarin sodium have increased risk of haemorrhage in the perioperative period. Warfarin sodium should normally be discontinued preoperatively and restarted as soon as is deemed safe postoperatively. The SIGN guideline on Antithrombotic Therapy suggests that surgeons intending to perform surgery or invasive procedures in patients receiving anticoagulant therapy seek advice concerning the management of such therapy from a haematologist.57 The guideline suggests that after warfarin sodium therapy is restarted following surgery it takes about three days on average for the international normalised ratio (of the prothrombin time) (INR) to increase above 2.0.
Hypothermia occurs in patients undergoing surgery because of anaesthetic-impaired thermoregulation, cold operating environments, open body cavities and the administration of unwarmed IV fluid. Without active methods to retain or provide heat approximately half of all patients undergoing surgery develop a core temperature of less than 36oC and in one third of patients the temperature drops below 35oC. In a prospective randomised controlled trial forced air warming, used both intraoperatively and postoperatively, maintained a core temperature significantly higher than non-heated controls (36.7 +/- 0.1oC versus 35.3 +/- 0.1oC, p = 0.0001).58 The maintenance of normothermia using a forced air warming technique intraoperatively and postoperatively is also associated with fewer cardiac events (eg cardiac arrest, myocardial infarction and/or unstable angina or ischaemia occurring in the first 24 hours postoperatively) in elderly patients undergoing abdominal, vascular and thoracic surgery.58 CS CS Maintain normothermia in the postoperative period. Active warming is appropriate for patients who are hypothermic postoperatively.
Patients with coronary artery disease are at risk from ischaemia in the first few postoperative days. The effect of anaesthesia and analgesia on respiratory function predisposes patients to hypoxia postoperatively. The potential for hypoxia may remain for up to five days postoperatively, 59 and is increased at night.
3 CARDIOVASCULAR MANAGEMENT
For most patients there is no consistent evidence regarding the relationship between hypoxia and ischaemic events postoperatively. In high risk patients undergoing vascular surgery, new ischaemic changes have been shown to be associated with a fall in oxygen saturation.60 Myocardial ischaemia has been shown to be more likely when episodes of hypoxia are prolonged beyond five minutes and are severe (SpO2<85%).61 See sections 4.3.3 and 4.5.2 for further information. CS
Patients with coronary artery disease, or major risk factors for coronary artery disease, should receive oxygen continuously until mobile. Oxygen saturation should be maintained above 92%.
Even patients with stable cardiac failure may not tolerate anaemia, tachycardia or intravascular volume shifts. Features of cardiac failure are shown in Table 7. Patients on drug treatment for established cardiac failure should have their medication continued throughout the perioperative period where possible. It may be necessary to use an IV loop diuretic where oral intake is not possible. If cardiac failure is suspected in the postoperative period:
n n n n n
examine patient thoroughly assess IV fluid regimen and drugs order ECG and chest X-ray request specialist advice for assessment and possible echocardiogram if patient in acute distress consider IV furosemide 40-80 mg.
Table 7: Features of cardiac failure FEATURES OF LEFT HEART FAILURE include lung crepitations dyspnoea pulmonary oedema on chest X-ray gallop rhythm FEATURES OF RIGHT HEART FAILURE include peripheral oedema raised JVP hepatic enlargement and occasionally tenderness PRECIPITATING FACTORS acute myocardial infarction or ischaemia arrhythmia (including loss of heart rate control in patients with established atrial fibrillation) anaemia fluid overload pulmonary thromboembolism drugs added, eg non-steroidal anti-inflammatory drugs drugs omitted, eg diuretics NB None of these signs are specific for cardiac failure and must be assessed in the clinical context.
POSTOPERATIVE MANAGEMENT IN ADULTS
Pulmonary complications are an important and common cause of postoperative morbidity and mortality and are particularly common after major abdominal and thoracic surgery. Reported incidence varies from about 20-75%,62-64 perhaps because of inconsistent diagnostic criteria. If patients at risk can be recognised, it may be possible to modify some risk factors before elective surgery to reduce the rate of these complications. Early recognition of developing respiratory complications with appropriate interventions may improve outcome. Failure to recognise pulmonary complications may result in rapid deterioration leading to death. Treatment must be based on an accurate assessment of the patient. In some cases no specific treatment is required but in others rapid and aggressive treatment is required to prevent death.
A number of risk factors for postoperative pulmonary complications have been identified: 65-70
n n n n n n n n n n n n n n n n n n n n
duration of anaesthesia66 nasogastric intubation66,67 type of surgery65 functional status65 ASA >2 68,69 age >59 68,70 body mass index >25 kg/m2 68 or BMI >27 kg/m2 70 weight loss65 smoking history within last eight weeks65,70 upper abdominal incisions68,70 chronic bronchitis65,68 presence of cancer68 stroke65 increased blood urea65 transfusion65 emergency surgery65 smoking, alcohol, and long term steroid use65 intermittent positive pressure ventilation (IPPV) >1 day67 impaired cognitive function65,70 preoperative stay >4 days.65 patients requiring IPPV may already have pulmonary complications patients requiring prolonged preoperative stay may have other problems and may also have an ASA >1 cognitive function may be impaired before operation or may develop as a result of the intervention and be caused by pulmonary complications.
The evidence supporting some of these risk factors is tenuous and may be circumstantial:
Other risk factors for which there is no specific evidence include oesophageal problems such as pharyngeal pouch, hiatus hernia, achalasia and intestinal obstruction.
4 RESPIRATORY MANAGEMENT
REDUCING POSTOPERATIVE PULMONARY COMPLICATIONS
ANALGESIA Compared with systemic opioids, neuroaxial blockade after surgery can reduce pulmonary complications; epidural opioids (RR 0.53 95% CI 0.2-1.33), epidural local anaesthetics (RR 0.58 95%CI 0.42-0.80), and intercostal nerve blocks (RR 0.47 95% CI 0.12-1.22).71 A large multicentre comparison of high risk patients having abdominal surgery found that analgesia with epidural after surgery did not improve survival (5.1% vs 4.3%) or major morbidity.72 Only one of eight categories of morbid end points in individual systems (respiratory failure) occurred less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). In this study, the term respiratory failure is a pooled end point covering need for prolonged intubation or reintubation, or a PaO2 ≤ 50 mm Hg or a PaCO2 ≥ 50 mm Hg on room air. These criteria may not all be clinically relevant.
POSTOPERATIVE FLUID BALANCE Following surgery the capacity to excrete fluid is reduced. Fluid accumulation, particularly in the lungs, may result in oedema. Cardiac and pulmonary complications and mortality after pneumonectomy are more common if fluid balance is strongly positive 73 and this association also appears to be relevant after non-thoracic surgery.74 Fluid balance following surgery must be very carefully controlled to avoid excess fluid accumulation (see section 5).
OXYGEN THERAPY Oxygen is often given to patients after surgery but good evidence supporting its routine use is scarce. The theoretical concern that nitrous oxide excretion may cause postoperative hypoxia has not been substantiated.75 One study has shown that increasing FiO2 after operation reduces the incidence of wound infection.76 Hypoxaemia is common after surgery and is caused by impaired gas exchange and impaired ventilatory control. Episodes of minor hypoxaemia after surgery are common but are of doubtful significance. Routine use of oxygen in fit patients after uncomplicated surgery, with SpO2 values over 92% has not been shown to reduce the incidence of hypoxaemia.77 Hypoxaemia in the postanaesthesia recovery room is not related to general postoperative morbidity.78 The threshold for adverse effects of hypoxaemia in individual patients however, is unknown and all patients should receive oxygen in the early postoperative period. The following groups of patients are at risk of persistent hypoxaemia and should receive prolonged monitoring and oxygen therapy:
n n n n
obese patients patients who have undergone thoracic or upper abdominal surgery patients with acute and chronic pulmonary disease patients receiving sedative drugs and opiates.
In some patients oxygen delivery to the tissues may be impaired despite a normal PaO2. This includes patients with:
n n n n n n n
These patients should also receive prolonged monitoring and oxygen therapy. CS Oxygen therapy should be used in those patients at high risk of postoperative complications, or who are hypoxaemic following surgery (SpO2< 92%).
POSTOPERATIVE MANAGEMENT IN ADULTS
MONITORING AND DIAGNOSIS
INTRODUCTION The widely accepted methods of monitoring patients have not generally been subject to evidence based assessment. An RCT of 20,802 patients found no difference in the incidence of postoperative complications between those routinely monitored with pulse oximetry and those not routinely monitored. Monitored patients had significantly more episodes of hypoxaemia identified and had fewer episodes of ECG detected myocardial ischaemia. 79,80 No other trials of routine monitoring were identified.81
DIAGNOSTIC CRITERIA The generally accepted diagnostic criteria for respiratory failure, pulmonary infections, acute respiratory distress syndrome (ARDS) and acute lung injury are as follows: Respiratory failure
Type 1 PaO2 < 8kPa (60 mm Hg), PaCO2 <6.6kPa (50 mm Hg) Type 2 PaO2 < 8kPa (60 mm Hg), PaCO2 >6.6kPa (50 mm Hg). Pulmonary collapse clinically or on X-ray which may be subsegmental, segmental, lobar or pulmonary, without evidence of respiratory infection.
Respiratory infection Any two of the following on two or more days:
n n n n
Pyrexia >38oC Positive sputum culture Positive clinical findings Abnormal chest X-ray Atelectasis/infiltrates. Acute onset Bilateral infiltrates on chest radiography Pulmonary artery capillary wedge pressure (PACWP) ≤18 mm Hg or the absence of clinical evidence of left heart failure Acute lung injury is considered to be present if PaO 2 (kPa) / FiO2 is ≤ 40 ARDS is considered to be present if PaO2 (kPa) / FiO2 is ≤ 26.
Acute respiratory distress syndrome and acute lung injury:
n n n
OBSERVATION Simple measures are most appropriate in view of the absence of evidence of efficacy of more sophisticated measures.82 The following indicate the possible development of respiratory complications:
n n n
respiratory rate <10 or >25 breaths per minute pulse rate >100 beats per minute reduced conscious level and/or confusion.
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Clinical assessment of the chest should be performed. Adventitial sounds on breathing are common and need not indicate significant disease but major abnormalities such as gross pulmonary collapse and pleural effusions are easily detectable. CS CS Respiratory rate, pulse rate and conscious level should be monitored routinely to identify postoperative respiratory complications. The following indicate the possible development of respiratory complications: n Respiratory rate <10 or>25 breaths per minute n Pulse rate >100 beats per minute n Reduced conscious level.
INVESTIGATIONS Specific and non-specific investigations are available and should be used as indicated clinically.
Pulse oximetry. It may be difficult to obtain a satisfactory signal if peripheral circulation is poor. Patients receiving supplemental oxygen may have adequate oxygen saturation despite hypoventilation and hypercapnia. Arterial blood gas analysis (ABG). ABG is essential in the assessment of any patient with suspected respiratory complications. ABG accurately defines the degree of respiratory failure and differentiates between metabolic and respiratory acidosis. Chest X-ray. Chest X-rays should be used to diagnose or exclude major collapse, pulmonary embolism and pleural problems such as effusions, pneumothorax or haemothorax. Routine X-rays are of limited value, even in patients who have had thoracic surgical procedures.83 Small areas of atelectasis are common but not necessarily significant. Diffuse pulmonary infiltrates may be caused by conditions such as cardiac failure, infection and ARDS. CT scan. Valuable in the accurate assessment of pulmonary masses, pulmonary embolism or major pleural disease such as empyema. It has no place in the routine management of postoperative pulmonary complications. Bacteriology. Sputum culture is of value in planning appropriate antibiotic therapy. Specimens taken by endobronchial suction may be used. ECG. Significant respiratory compromise may relate to a primary cardiac event, and so all patients who are investigated for pulmonary complications should also have an ECG.
Patients in whom there is a suspicion of postoperative pulmonary complications should have an arterial blood gas analysis, a sputum culture and ECG. Chest X-ray should be performed on suspicion of major collapse, effusions, pneumothorax or haemothorax. Other investigations should be used only if there are specific indications.
TREATING ATELECTASIS Atelectasis is common after surgery, particularly pulmonary and upper abdominal surgery. Prevention and clearance of atelectasis is important to prevent secondary infection. In most cases no specific treatment is required beyond normal mobilisation and breathing exercises. Hypoxia requires oxygen therapy as described in section 4.5.2. Very occasionally where physiotherapy fails to effectively treat extensive lobar or pulmonary collapse, therapeutic bronchoscopy and bronchial suction may be necessary as the collapsed lung contains no air with which to cough out the mucus plugs.
TREATING RESPIRATORY INFECTION Treatment should aim to maintain oxygenation, clear blocked airways, expand collapsed alveoli and clear infection.
POSTOPERATIVE MANAGEMENT IN ADULTS
Oxygen therapy Oxygen can be delivered by a large number of different devices. 100% oxygen can only be supplied by endotracheal intubation and positive pressure ventilation. The highest inspired concentration that can be supplied by external devices is about 70% with a mask and reservoir bag. A 60% ventimask can reliably supply sufficient oxygen for most patients with respiratory insufficiency.84 A selection of fixed performance devices (ie providing a fixed FiO2) are available, allowing delivery of an FiO2 appropriate to individual patients. Hudson masks and nasal catheters with a foam collar allow better PaO2 than nasal catheters, but there is no difference in oxygen saturation between the three devices.85 Hudson masks, when used with low flow oxygen, may result in hypercapnia due to inadequate ventilation. Nasal catheters are better tolerated and therefore compliance is better.86 In a normally hydrated patient humidification of oxygen is not necessary unless the patient is intubated with an endotracheal tube or has a tracheostomy. Patients with type 2 respiratory failure due to chronic obstructive pulmonary disease (COPD) have chronic CO2 retention and are dependent on hypoxic drive. They should be given whatever FiO2 is necessary to return their SpO2 to its usual level. Table 8: Equipment used for oxygen delivery Type of mask Nasal catheters (± foam) Hudson mask Venturi mask with venturi jet Venturi mask attached to humidification system Reservoir mask Characteristics of system Low flow system Variable performance Low flow system Variable performance High flow system Fixed performance High flow system Fixed performance High flow system Fixed performance Rate or concentration of oxygen delivery 2-4 litre/min 4-8 litre/min 24,28,35,40,60% oxygen 28,35,40,60% oxygen 70% oxygen
Oxygen should be given to patients with hypoxaemia using a device that is best tolerated to achieve the necessary SpO2. In normally hydrated patients humidification is unnecessary. Failure to maintain an SpO2 >90% or PaO2 >8.0 kPa is an indication to consider assisted ventilation.
Antibiotics Patients fulfilling the diagnostic criteria for respiratory infection (see section 4.4.2) should be treated with appropriate antibiotics, based on local protocols and represcribed later on the basis of the results from sputum culture.87 Any patient in whom aspiration may be suspected should receive additional cover for anaerobic organisms. Continued monitoring of sputum bacteriology is necessary as treatment failure is associated with development of drug resistance and change in bacteria.87 CS Patients with evidence of respiratory infection should receive antibiotics based initially on local protocols and modified later on the basis of the results from sputum culture. If aspiration of intestinal contents is suspected additional cover for anaerobic organisms should be given.
4 RESPIRATORY MANAGEMENT
TREATMENT OF RESPIRATORY FAILURE Respiratory failure may be purely a ventilatory problem and in the postoperative period this may be due to one of a variety of drugs. It is important to identify drug related problems as specific antidotes are available. Drugs Many drugs depress ventilation. Specific antagonists are available for the commoner suppressant drugs namely opioids, neuromuscular blocking agents and benzodiazepines. Specific respiratory stimulants may also be appropriate. It is important to remember that antagonists usually have a shorter action than agonists and dosage may have to be repeated. Antagonists such as naloxone hydrochloride or flumazenil should be given carefully because acute reversal can cause acute pain, withdrawal symptoms, or fits. CS CS CS Opioid overdose should be treated with oxygen, airway maintenance, ventilatory support if necessary, and immediate anaesthetic or critical care specialist advice. Benzodiazepine overdose should be treated with oxygen, airway maintenance, ventilatory support if necessary, and immediate specialist advice. Hypoventilation due to CNS depression not responsive to specific antagonists is an indication for specialist anaesthetic or critical care referral.
Assisted ventilation In patients who develop respiratory failure assistance with breathing may be necessary. Assisted ventilation is required when a patient develops hypercapnia and occasionally for severe hypoxaemia (see section 4.4.2. for definitions). Accepted criteria for ventilation are: In a patient receiving FiO2 of 0.6:
n n n
PaCO2 >6.6kPa PaO2 < 8.0kPa Respiratory rate >25 breaths/min. Patients developing respiratory failure should be referred to a critical care specialist to be assessed for possible assisted ventilation. The referral should be timely as hypoxia or hypercapnia may lead rapidly to cardiorespiratory arrest.
ROLE OF PHYSIOTHERAPY
Physiotherapy is widely used before and after surgery. As this is an under-researched area, limited high quality evidence is available. In addition, the evidence that was identified addresses techniques that tend not to be used in current practice. Further research regarding the role of postoperative physiotherapy would be beneficial. Although evidence for its efficacy is variable, physiotherapy may be useful in patients with:
n n n n
decreased lung volume sputum retention increased work of breathing reduced exercise tolerance.
POSTOPERATIVE MANAGEMENT IN ADULTS
Following general anaesthetic, a patients functional residual capacity may be lowered, particularly following upper abdominal or thoracic surgery. Reduction in lung volume reduces lung compliance, increases airway resistance and may lead to atelectasis. The aims of postoperative physiotherapy are to:
n n n n n
facilitate re-expansion of atelectasis maintain adequate ventilation assist with the removal of bronchial secretions encourage early mobility promote return to preoperative functional levels.
A combination of these approaches may help to maintain respiratory function and prevent early postoperative respiratory complications. Other treatment techniques are available for patients with more complex needs. There should be a multidisciplinary approach to the promotion of optimal positioning and early mobilisation. 4.6.1 TREATMENT OPTIONS Table 9: Summary of common physiotherapy treatments Effect required Increase lung volume Treatments available Positioning Thoracic expansion exercises Controlled mobilisation Active exercise programme Mechanical aids, eg incentive spirometer, intermittent positive pressure breathing (IPPB) Systemic hydration/humidification Airway clearance techniques Thoracic expansion exercises Mobilisation Manual techniques Mechanical aids Suction Rest and sleep Positioning Breathing control exercises Breathing re-education Mechanical aids/assisted ventilation
Reduce work of breathing
Adequate analgesia prior to physiotherapy will allow more patients to participate in treatment. Local treatment protocols may be in place for specific patient groups. 4.6.2 REDUCING POSTOPERATIVE PULMONARY COMPLICATIONS Postoperative pulmonary complications have been reduced from 60% to 19% with simple supervised breathing exercises in patients undergoing upper abdominal surgery88 and major abdominal surgery (from 27% to 6%, p<0.001), with the addition of resistance training in high risk patients.89 Devices such as incentive spirometers have not been consistently shown to be better than standard breathing exercises.90
4 RESPIRATORY MANAGEMENT
Retention of sputum is common and assistance with breathing and positioning helps expectoration. Additional use of humidification in patients with very viscid secretions may help expectoration. Patients with evidence of collapse or decreased lung volume on X-ray, and those who have had recent abdominal surgery may also benefit from physiotherapy. Postoperative pain, particularly in upper abdominal or chest surgery, may cause difficulty with deep breathing and coughing. Both are essential in the treatment of respiratory infections, making appropriate positioning of the patient important. Patients often find the sitting position helpful for breathing. This is also a more comfortable position in patients with respiratory distress. CS CS CS The patient should be encouraged to sit up and should be given sufficient analgesia, which may include epidural anaesthesia, to allow breathing exercise and coughing. Patients with sputum retention should be assessed by a physiotherapist. Patients with collapse or decreased lung volume or who have undergone recent thoracic or abdominal surgery should be considered for physiotherapy.
OUT OF HOURS SERVICES Most hospitals also operate an out of hours respiratory physiotherapy service for emergencies, with local guidelines giving details of service provision.91 Table 10 gives a guide to when out of hours physiotherapy may be appropriate. Table 10: When to use out of hours physiotherapy services CRITERIA FOR EMERGENCY CALL-OUTS The patient has a condition that is amenable to physiotherapy which has either: n deteriorated n or is likely to deteriorate without intervention before the daytime service resumes PROBLEMS WHICH MAY BE HELPED BY PHYSIOTHERAPY Secretion retention which is compromising ventilation Acute lobar collapse Acute aspiration DO NOT CALL FOR Respiratory compromise due to pain, until pain is controlled Sputum retention due to dehydration, until patient is rehydrated Bronchospasm Pulmonary embolism Reduced lung volume due to pleural effusion Pulmonary oedema/fluid overload
POSTOPERATIVE MANAGEMENT IN ADULTS
Fluid, electrolyte and renal management
There is surprisingly little primary research on this important topic. There are studies based on specialist populations, including those in ICU, and on preoperative optimisation. Many of these studies are small and have methodological flaws. The guideline development group did not feel that the results of trials in different populations could be used as evidence to guide management of the postoperative patients covered by this guideline. Acute renal failure can be defined in terms of creatinine clearance or a rise in serum creatinine from the baseline value. Creatinine clearance is seldom measured in postoperative patients and decisions are generally made on the basis of serum creatinine. Patients may have serum creatinine within the normal laboratory range and still have significant impairment of function. This is particularly the case in patients who are debilitated or elderly. The SIGN guideline on perioperative blood transfusion for elective surgery provides guidance on the use of packed cells in the postoperative period.92
BASAL REQUIREMENTS IN THE POSTOPERATIVE PATIENT CS The basal requirements for young adults are approximately 30 ml/kg/day of water, 1.01.4 mmol/kg/day of sodium and 0.7-0.9 mmol/kg/day of potassium.
Given that fat is relatively metabolically inert and that the percentage of fat relative to lean mass tends to increase with age, the standard calculations above are particularly likely to overestimate the basal needs of the obese, the elderly and women. 5.1.2 PRINCIPLES OF FLUID BALANCE As in any patient, the standard principles of fluid balance in the postoperative patient are:
n n n n
to correct any pre-existing deficit to supply basal needs to replace unusual losses (eg from the pre-existing surgical problem, surgical drains, pyrexia) to use the oral route where possible; there is often an unnecessary delay in commencing oral intake after surgery.
There is a longstanding conflict between wet and dry schools, particularly with regard to prevention of complications and correction of pre-existing deficits. The wet school offers evidence that some patients benefit from aggressive preoperative fluid loading as part of a pre-optimisation strategy (guided by invasive monitoring). The dry school contends that, due to stress-related changes in endocrine function, many patients do better with restriction of water and sodium intake. The advocates of both approaches often include them as part of a package of perioperative care. This guideline is concerned with postoperative care and not with these overall strategies. The evidence base for fluid management in the postoperative setting is poor, but it is important to avoid hypovolaemia in the early postoperative phase. 5.1.3 ROLE OF INVASIVE MONITORING Invasive monitoring of central venous pressure may help in assessing fluid balance status, especially in high risk patients (eg the elderly). The assessment of trends, particularly in response to a fluid challenge, is more important than a single reading.
5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT
Invasive monitoring should be considered to assess fluid balance status, particularly in high risk patients. Elderly patients should be observed closely as they are more likely to have overt or covert cardiac, respiratory or renal disease and to have less reserve. Clinical signs may be less reliable in these patients.
Risk factors for postoperative fluid or electrolyte disturbance could relate to:
n n n n n
the surgical condition medical problems complicating the surgical condition pre-existing medical problems (eg renal, cardiac or hepatic disease) medications such as diuretics problems of limited homeostasis in older patients making them susceptible both to over- and under-loading of fluids and electrolytes. the elderly those with pre-existing cardiovascular disease those with pre-existing cerebrovascular disease those with pre-existing renal disease those who have suffered perioperative myocardial ischaemia or infarction those who have suffered large perioperative fluid losses.
The following patients are particularly at risk:
n n n n n n
The ideal way of tackling problems with fluid and electrolyte balance is to avoid them in the first place. Appropriate monitoring strategies are discussed in section 2.4. The patients fluid status and electrolyte balance need to be estimated, taking into consideration:
n n n n
unusual losses as the result of the surgical problem prior to assessment continuing surgical-related losses usual maintenance needs vasodilating effects of epidural analgesia. Be aware that preoperative bowel preparation or prolonged preoperative fasting may result in covert hypovolaemia, which may become evident only in the early postoperative period. Assess hypotensive patients with epidurals to exclude fluid deficit. It should not be assumed that the hypotension is due to the epidural. Avoid excessive administration of fluids to hypotensive patients with epidural anaesthesia who are well perfused. This can cause fluid overload which may only become manifest when the epidural infusion is stopped.
DETECTION OF OVERT CLINICAL PROBLEMS
Patients should be monitored for problems such as:
n n n n n
hypotension tachycardia oliguria signs of fluid overload (such as pulmonary oedema) more subtle signs such as confusion or tachypnoea.
POSTOPERATIVE MANAGEMENT IN ADULTS
Hypotension, tachycardia, oliguria, confusion and tachypnoea may all be indications of hypovolaemia but also have other causes, including sepsis and primary cardiac problems. Whenever a postoperative patient is hypovolaemic, it is vital to consider blood loss, and to actively exclude this before attributing hypovolaemia to another cause. Management should be appropriate to the identified causal factor. CS Accurate assessment of fluid and electrolyte status can be difficult and the treatment of a particular patient must be individualised and reviewed frequently in the light of the response to treatment.
MANAGEMENT OF VOLUME DEPLETION AND OVERLOAD
VOLUME DEPLETION Volume depletion can lead to poor tissue perfusion and this can result in both morbidity and mortality. The specific consequences are:
n n n n
anastomotic breakdown cerebral damage renal failure multiple organ failure.
Table 11: Volume depletion Possible causes of volume depletion
unrecognised or uncorrected preoperative hypovolaemia (including effects of fasting) inadequate intra- or postoperative replacement, bearing in mind: n third space losses (fluid sequestration in the gut or peritoneal cavity, oedema) n drain losses n fistulae n polyuric renal failure n hyperventilation n pyrexia n nasogastric aspirate haemorrhage inappropriate use of diuretics. Volume depletion should be avoided as this can lead to poor perfusion and problems such as anastomotic breakdown, cerebral damage, renal failure and multiple organ failure.
VOLUME OVERLOAD Volume overload can lead to pulmonary and tissue oedema. Pulmonary oedema can be immediately life threatening. Tissue oedema can lead to poor tissue perfusion, failure to absorb enteral feed, and failure to eat.
5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT
Table 12: Volume overload Possible causes of volume overload Excessive fluid administration due to: n overestimation of loss (drain or third space losses) n failure to recognise deteriorating renal function n failure to recognise deteriorating cardiac function. CS Volume overload should be avoided.
Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours. The appropriate response depends on the cause and whether it is associated with impaired renal function. Oliguria should not be regarded as a diagnosis but as a sign requiring explanation. It is not appropriate to artificially increase the urine output in a hypovolaemic patient using diuretics. These should be reserved for patients who are fluid overloaded. Dopamine has been widely used in the past in the hope of preventing acute renal failure, but the overwhelming evidence from studies in critically ill patients is that it is not beneficial. Oliguria associated with normal pre-existing renal function, cardiovascular stability and an alert patient is unlikely to require intervention unless it persists for four hours or more. If associated with other symptoms or signs suggestive of fluid depletion it should be treated initially with a fluid challenge. Careful monitoring is required in patients with poor cardiac function. Colloid is preferred as the effect is more readily apparent, but crystalloid, such as normal saline, can also be used. In a normal adult, 250 ml colloid should be given over 30 minutes. It is essential to assess the response in terms of haemodynamics and subsequent urine output. If there is no improvement, this may be repeated once. If this does not produce improvement then consideration should be given to the measurement of central venous pressure. Smaller volumes may be appropriate in the frail elderly and those with cardiovascular disease. CS Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours. The appropriate response depends on the cause and whether there is pre-existing renal impairment. Oliguria in an alert patient, that is associated with normal pre-existing renal function and cardiovascular stability, is unlikely to require intervention unless it persists for four hours or more. If oliguria is associated with other symptoms or signs suggestive of fluid depletion it should be treated initially with a fluid challenge. In all cases of oliguria it is important to exclude obstruction of the urinary tract or urinary catheter. Diuretics should not be used to treat oliguria and should be reserved for fluid overload. Dopamine should not be used to treat oliguria or to prevent renal failure.
CS CS CS CS
POSTOPERATIVE MANAGEMENT IN ADULTS
HYPONATRAEMIA Hyponatraemia does not by itself indicate saline deficiency and is most commonly due to excess water. Antidiuretic hormone (ADH) secretion is increased after surgery and if excess water is given (as 5% dextrose) then hyponatraemia may be induced. If hyponatraemia is associated with volume depletion then there must be a degree of sodium deficiency. The estimation of the degree of volume excess or volume depletion requires clinical assessment in addition to biochemical estimates. Very low levels of serum sodium (110-120 mmol/L or less) can produce symptoms such as stupor, coma or fits and constitute a medical emergency. Over-vigorous correction of severe hyponatraemia is also dangerous. Patients with hyponatraemia should be managed by medical staff with appropriate experience. CS CS Assess volume status in hyponatraemic patients, as it is more commonly due to excess water rather than sodium deficiency. Severe hyponatraemia (Na<120 mmol/L) constitutes a medical emergency and should be managed by experienced medical staff.
HYPERNATRAEMIA In patients with hypernatraemia, clinical assessment of the patient may add little to the biochemical assessment, as water depletion initially leads to volume losses from the intracellular rather than the extracellular space. The signs and symptoms of water depletion tend to be non- specific, particularly where the sensation of thirst is impaired by the surgical or medical situation. CS Hypernatraemia most commonly indicates a total body deficiency of water and is an indication for prompt assessment and intervention, especially when levels exceed 155 mmol/L.
Potassium levels in the blood are not a good indicator of total body potassium. However, abnormal blood levels, and in particular hyperkalaemia may precipitate cardiac arrest, and an ECG is an important adjunct when deciding the potential ill effects of potassium abnormalities in an individual postoperative patient. Protocols for the emergency treatment of potassium abnormalities are described in standard emergency medicine texts. Most hospitals will also have local protocols which should be referred to. It is important to correct hypoxia and institute ECG monitoring.
HYPOKALAEMIA Chronic hypokalaemia indicates a significant deficit in total body potassium, which may be several hundred millimoles. The clinical effects of hypokalaemia include skeletal muscle weakness, ileus, and cardiac arrhythmias. It can also potentiate the adverse effects of digoxin. Acute hypokalaemia can result from shift of potassium into cells due to, for example, alkalosis, insulin or beta adrenergic stimulation (including nebulised beta agonists). True potassium deficiency in postoperative patients may result from:
n n n n
inadequate replacement renal losses endocrine abnormalities upper and lower GI losses (the actual loss of potassium from the upper GI tract is small, but the loss of chloride causes alkalosis which promotes the movement of potassium into cells and increases renal excretion).
5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT
Not only does alkalosis cause hypokalaemia, but hypokalaemia can cause alkalosis. Treatment of hypokalaemia should first focus on removing avoidable causes. Unless there is true potassium deficiency, it is seldom necessary to replace potassium at a rate of greater than 10-20 mmol/hr. Faster administration usually requires a central line and careful monitoring and should by undertaken in an environment which provides level 2 care. Concentrated solutions of potassium are intensely irritant to peripheral veins and can cause tissue necrosis if they extravasate. When correcting severe or persistent hypokalaemia, also ensure that magnesium is not deficient. Magnesium deficiency leads to increased renal loss of potassium. CS Hypokalaemia is a common problem and can delay postoperative recovery. Hypokalaemia should be avoided, or corrected, with appropriate supplementation. Magnesium supplementation may also be required.
HYPERKALAEMIA Emergency treatment of hyperkalaemia may include IV calcium chloride, which must be titrated slowly, IV calcium gluconate, nebulised beta agonists (such as salbutamol) or IV 50 ml 50% dextrose with 10 units of shortacting insulin. CS Hyperkalaemia is a medical emergency and senior help should be obtained.
Acute acid/base problems in the postoperative period are commonly due to respiratory/ventilation problems (see section 4). Metabolic acidosis is usually due to poor tissue perfusion but can also be due to renal failure, or rarely, can be caused by excessive administration of 0.9% saline which has a high chloride concentration.93 If large volumes of crystalloid are required then Hartmanns solution is preferable. A total venous bicarbonate of less than 20 mmol/L or a base deficit of greater than four may indicate cause for concern, particularly if the trend is adverse. CS Metabolic acidosis is usually due to poor tissue perfusion but can also be caused by excessive administration of saline. A total venous bicarbonate of less than 20 mmol/L or a base deficit of greater than 4 mmol/L may indicate cause for concern, particularly if the trend is towards progressive acidosis. Expert opinion should be sought.
POSTOPERATIVE MANAGEMENT IN ADULTS
Management of sepsis
Sepsis is the systemic inflammatory response to infection and represents a progressive response to infection leading to a generalised inflammatory reaction in organs remote from the initial insult and eventually to end-organ dysfunction and/or failure (see Table 13 for list of definitions). The development of systemic sepsis in a postoperative patient marks a serious decline in their condition. If associated with shock or organ dysfunction (sepsis syndrome) mortality is between 20 and 40%. Clearly identifying patients at risk and taking appropriate prophylactic measures is vital. Once a patient has developed sepsis syndrome however, the principles of early identification, immediate resuscitation, moving the patient up to the appropriate level of care (level 2 or 3), identifying the primary source, use of early and appropriate antibiotics and undertaking appropriate surgical drainage are the mainstays of treatment. Table 13: Definitions of sepsis Systemic inflammatory response syndrome: SIRS The response is defined by the presence of two or more of the following: 0 0 n temperature >38 C or <36 C n heart rate >90 beats/min n respiratory rate >20 breaths/min or PaCO <4.3kPa 2 3 3 n white cell count >12,000 cells/mm , <4,000 cells/mm , or >10% immature forms. Sepsis SIRS plus documented site of infection Severe sepsis Sepsis associated with organ dysfunction, hypoperfusion or hypotension (septic shock). Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic acidosis, oliguria or an acute alteration in mental state.
RISK FACTORS FOR INFECTION
Several studies have identified a series of risk factors for postoperative infection, outlined in Table 14. Minimising the risk of infection in such patients is logical and should be an integral part of their care pathway. Table 14: Risk factors for postoperative infection complicated surgery, eg total gastrectomy > than other gastroduodenal procedures94 prolonged operation time94-96 blood transfusions94,95 hypothermia increasing age95,97 presence of remote infection96,98 or faecal contamination98 male sex98 poor physical status of patient,98 malnutrition, immunocompromise, severe underlying disease emergency surgery95 use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage)95 prolonged intravascular cannulation prolonged postoperative stay96 patients receiving chemotherapy or radiotherapy, immunosuppressants, steroids severe trauma or burns There is little evidence to demonstrate how these factors influence or predict outcome.
6 MANAGEMENT OF SEPIS
ANTIBIOTIC PROPHYLAXIS Antibiotic prophylaxis in surgery has previously been reviewed by SIGN (for recommendations see SIGN guideline on Antibiotic Prophylaxis in Surgery).99 CS Prophylactic antibiotics should be administered to appropriate groups of patients to reduce the risk of developing postoperative sepsis.
HAND WASHING Hand washing is widely recognised as an important but underused measure to prevent nosocomial infections.100 Guidelines exist for handwashing techniques.101 The following statements are based on these guidelines: 1. Hands (when visibly soiled) must be washed thoroughly with soap and water. 2. Hands must be cared for by hand washing with soap and water or by hand antisepsis with alcohol based handrubs (if hands are not visibly soiled): a) before and after patient contact b) after contact with a source of micro-organisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated) c) after removing gloves. 3. Hand antisepsis, achieved by hand washing or surgical scrub with antimicrobial-containing soaps or detergents or by use of alcohol based antiseptic handrubs, is recommended in the following instances: a) before the performance of invasive procedures such as surgery or the placement of intravascular catheters, indwelling urinary catheters, or other invasive devices b) when persistent antimicrobial activity on the hands is desired c) when it is important to reduce numbers of resident skin flora in addition to transient micro-organisms. CS CS Hand washing with soap and water or with alcoholic cleansing agents should be performed before and after patient contact. Strict hand antisepsis must be achieved before the performance of invasive procedures such as surgery or the placement of intravascular catheters, indwelling urinary catheters, or other invasive devices.
Other aspects of hand care and protection: Glove use
n n n
gloves should be used as an adjunct to, not a substitute for, handwashing gloves should be used for hand-contaminating activities gloves should be removed and hands washed when hand-contaminating activity is completed, when the integrity of the gloves is in doubt, and between patients gloves may need to be changed during the care of a single patient, for example when moving from one procedure to another disposable gloves should be used only once and should not be washed for reuse gloves made of other materials should be available for personnel with sensitivity to usual glove material (such as latex), and for use in patients with a similar sensitivity.
Behaviour and compliance Efforts to improve hand washing practice should be multifaceted and should include continuing education and feedback to staff on behaviour or infection surveillance data. Unit clinical and administrative staff should be involved in the planning and implementation of strategies to improve compliance and hand washing.
POSTOPERATIVE MANAGEMENT IN ADULTS
Gloves should be used for hand-contaminating activities. Gloves made from a range of materials should be available for personnel with sensitivity to standard glove material, and for use in patients with a similar sensitivity.
Early identification and management of sepsis is vital as the prompt administration of appropriate empirical antimicrobial therapy reduces by half the frequency with which shock develops in patients with rapidly fatal, ultimately fatal and non-fatal diseases.102
CLINICAL FEATURES The early clinical signs of sepsis are variable and often non-specific. Patients at high risk require a high index of suspicion. One group at particular risk is that with an anastomosis of the GI tract. Anastomotic leakage carries a mortality rate of 20-50%.The list of clinical signs of sepsis in Table 15 has been adapted from Matot et al.103 Table 15: Clinical signs of sepsis Fever/hypothermia Unexplained tachycardia Unexplained tachypnoea Signs of peripheral vasodilation Unexplained hypotension/shock Changes in mental state Leucocytosis/neutropenia Unexplained alteration in renal or liver function Thrombocytopenia/ disseminated intravascular coagulation Metabolic acidosis
IDENTIFICATION OF SEPSIS Early identification of systemic sepsis involves:
focused clinical examination, for both a primary site of infection and the systemic sequelae of sepsis examination for primary site of infection (guided by risk factors); exposure of surgical wounds, vascular access sites, pressure areas, injection sites. Wound swabs or specimens of drain fluid should be obtained from the suspected wound infection. Examination of chest, examination of urine. Microscopy and/or dipstix testing for nitrites may give an early indication of infection, before formal sensitivities from culture are available examination for systemic sequelae; include measurement of temperature, respiratory rate, heart rate, blood pressure and laboratory investigation of neutrophil count 104 severity of sepsis may be assessed by looking for organ dysfunction which may be reflected by altered platelet count, coagulation screen, renal function, liver function and C-reactive protein. Early identification and appropriate treatment of sepsis improves outcome. Urine and blood cultures should be obtained whenever there is reason to suspect systemic sepsis. If clinical signs are unclear, appropriate radiological investigations should be used for the diagnosis of intra-abdominal infection.
CS CS CS
6 MANAGEMENT OF SEPIS
DIAGNOSTIC PROCEDURES No evidence was identified to inform timing of blood culture in relation to clinical signs. Expert opinion suggests that blood cultures should be taken as soon as possible following onset of fever.105 Three samples, totalling 60 ml should be taken over a 24 hour period. The accuracy of CT and ultrasonography for the diagnosis of intra-abdominal abscesses has been compared.106 ,107 The accuracy of ultrasound ranges from 75-96% while CT correctly diagnoses 71-100%. CT and ultrasonography may be complementary.
Once a patient has been identified to be septic, further diagnosis and treatment usually occur in parallel. Immediate care demands assessment of airways, breathing and circulation (the ABCs). The patient will often be hypovolaemic and hypoxaemic and the presence of these changes demands at least the administration of oxygen and establishment of intravenous access with volume expansion using either colloid or crystalloid. Patients with sepsis syndrome need careful monitoring and, in general, require level 2 care. Once a patient has been examined fully and initial diagnostic tests undertaken, antibiotics should be given as early as possible and are generally prescribed on a best guess basis for the clinical scenario.
ANTIMICROBIAL THERAPY IN SEPSIS Antimicrobial therapy is the cornerstone of management of patients with sepsis. Results from analysis of microbial specimens, and any proposed changed in antibiotic therapy may need to be reviewed with the consultant microbiologist. There are few comparative studies on the efficacy and safety of different antimicrobial regimens in non-neutropenic or postoperative patients. Treatment guidelines for patients with sepsis have been based on the results of large, multicentre studies conducted in neutropenic cancer patients.108 Retrospective studies have shown that early administration of appropriate, broad spectrum109 antibiotics reduces mortality.110 CS CS CS If the cause of sepsis is unknown, treatment should be with broad spectrum antibiotics, guided by local protocols. The results from microbiological specimens should be reviewed regularly and antibiotics changed as necessary. A course of antimicrobial treatment should generally be limited to 5-7 days. It is important to appreciate that fungi and atypical organisms can contribute to sepsis syndrome, and to take cultures and prescribe appropriately.
SURGERY Surgical approaches to the treatment of infection have evolved through principal and tradition and few have been evaluated by randomised controlled trials. Localised collections of pus generally need either operative or percutaneous drainage and dead tissue should be excised. Severe pulmonary sepsis may require bronchoscopy and toilet of the bronchial tree. Early intervention in necrotising soft tissue infection has been shown to reduce mortality compared to historical controls in some case series.111 CS Surgical intervention in the form of debridement or drainage of infected, devitalised tissue should be undertaken as soon as possible following haemodynamic stabilisation.
Abdominal sepsis, if localised, can be managed initially with antibiotics or percutaneous drainage, but generally the primary source of sepsis must be treated surgically (eg anastomotic leakage). Meticulous attention to peritoneal toilet with copious lavage is essential. The role of planned second-look laparotomy is still not clear. There are no randomised controlled trials comparing percutaneous and operative drainage techniques. Case series show that percutaneous drainage is as effective as conventional surgery for the drainage of intra-abdominal collections.112,113
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Percutaneous drainage following radiological identification should be considered for well defined collections. Patients with multiple collections or with failure of percutaneous drainage should have open surgery.
OTHER INTERVENTIONS Obstruction of the biliary or urinary system must be relieved usually by endoscopic or percutaneous radiological means. Major sepsis associated with an infected prosthesis most commonly demands removal of the latter. It is essential to remain vigilant about the possibility of catheter-related sepsis, particularly in patients receiving level 2 or 3 care. Short term, high concentration oxygen after surgery reduces wound infection.75
7 POSTOPERATIVE NUTRITION
For normally nourished patients, the primary objective of postoperative care is restoration of normal GI function to allow adequate food intake and rapid recovery. Malnourished patients are at increased risk of postoperative complications and mortality, yet artificial nutritional support can be associated with major complications.114 This section discusses a number of key issues that should be addressed if restoration of oral food intake is to be achieved quickly and safely.
AVOIDING ROUTINE NASOGASTRIC INTUBATION
To promote a return to normal dietary intake, the presence of a nasogastric (NG) tube should be avoided. Evidence from several randomised trials 115 and a meta-analysis 116 indicates that avoiding routine nasogastric decompression after abdominal surgery significantly reduces the incidence of fever, atelectasis and pneumonia.
PROMOTION OF EARLY ORAL INTAKE A meta-analysis of controlled trials (11 studies with 837 patients) of early enteral feeding versus nil by mouth after GI surgery, concluded there is no clear advantage to keeping patients nil by mouth after elective GI resection.117 Early feeding reduced both the risk of any type of infection (RR 0.72, 95%CI 0.54 0.98, p = 0.036) and the mean length of stay in hospital (number of days reduced by 0.84, 0.36 to 1.33 P = 0.001). The risk of vomiting increased in patients fed early (RR 1.27, 95% CI 1.01 1.61, p=0.046). For patients with an anastomosis in the upper GI tract, ingestion of solid food may have to be delayed for several days (eg until contrast studies confirm an intact oesophageal anastomosis). Following colorectal operations where the GI tract remains functional (see section 7.2.4) solid food can be commenced without adverse effect on the first postoperative day.118 Patients may find liquid supplements easier to take in the first instance. CS Oral intake should be commenced as soon as possible after surgery.
PROVISION AND ACCESS TO APPETISING FOOD Studies in hospital patients have shown that up to 20% of meals are missed while patients attend or are fasted for investigative or therapeutic interventions, whilst 40% of the content of meals delivered to the patient is discarded.119 The provision of appetising hospital food and access to sufficient nursing staff to help patients who have difficulty in eating is a key issue in helping patients return to a normal food intake. CS CS Patients should not be fasted for any longer than necessary, either for investigations or surgery. Hospitals should provide appetising food and assist patients to eat, if this is needed.
NUTRITIONAL STATUS AND POSTOPERATIVE NAUSEA AND VOMITING The control of postoperative nausea and vomiting is essential if patients are to resume normal oral fluid and dietary intake. The regular use of anti-emetics is advised. CS Anti-emetics should be used as required in order to promote an early return of oral intake.
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PREVENTION OF POSTOPERATIVE ILEUS The effect of early enteral feeding on ileus is controversial. No data were identified from randomised clinical trials on the effect of laxatives on postoperative paralytic ileus.
USE OF ORAL SUPPLEMENTS Patients who are malnourished either at the time of, or shortly following, major abdominal or vascular surgery have a more rapid recovery of nutritional status, physical function and quality of life, if given nutritional advice and prescribed routine oral supplements in the immediate postoperative period and following two months.120 The evidence supporting the short term routine use of oral supplements in patients who are not malnourished is not clear.121,122
MULTIMODAL RECOVERY PROGRAMMES Use of early oral or artificial enteral nutrition at a time when gastrointestinal function has not returned to a suitable level can be associated with abdominal distension, vomiting and respiratory embarrassment.123 Multimodal enhanced recovery programmes (with a focus on pain control, early mobilisation and promotion of gastrointestinal function) are associated with an early return of oral nutrition in the postoperative period.124 ,125 Patient care pathways should be designed to take account of a multimodal approach.
NUTRITIONAL SUPPORT FOR MALNOURISHED PATIENTS
Protein/calorie undernutrition can vary from mild (eg <5% weight loss) to severe (eg >15% weight loss, BMI <18kg/m2, albumin <30 g/l) and can occur in patients undergoing surgery for benign or malignant disease. The need for nutritional support should be considered in relation to each patients nutritional status and surgical pathology. Patients who are identified as malnourished should be referred to the unit dietitian for further assessment and management.
MALNUTRITION AND SURGICAL RISK; SCREENING TOOLS Patients who are malnourished are at increased risk of postoperative complications.126,127 A variety of strategies have been suggested for screening patients for malnutrition in the community, but it is not clear whether their implementation reduces morbidity or mortality.
MALNUTRITION IN BENIGN DISEASE There is no evidence that malnourished patients with benign disease and requiring surgery (eg Crohns disease) benefit from prolonged preoperative artificial nutritional support. Such patients are best treated by surgical correction of their pathology followed by intensive nutritional support in the postoperative period. CS Malnourished patients with benign disease requiring surgery should receive postoperative nutritional support by the appropriate route.
MALNUTRITION IN MALIGNANT DISEASE There is some evidence to suggest that severely malnourished patients with cancer benefit from perioperative total parenteral nutrition (TPN).128 This benefit does not pertain to cancer patients with mild or moderate malnutrition, where a meta-analysis has shown that perioperative TPN has no benefits in terms of mortality.129 Upper GI cancer patients are often given postoperative enteral feeding either via a jejunostomy or fine-bore nasoenteral feeding tube. This allows maintenance of nutritional status should the patient develop a postoperative complication that retards normal progression towards oral nutrition (eg an anastomotic leak).
7 POSTOPERATIVE NUTRITION
A meta-analysis has demonstrated that enteral nutritional support supplemented with immunomodulatory nutrients results in a significant reduction in the risk of developing infectious complications but has no effect on mortality.130 The cost effectiveness of such a strategy has not been clearly established. Immunonutrition may be given preoperatively as well as postoperatively.131 CS CS Mild or moderately malnourished cancer patients should proceed with surgery and only receive artificial nutritional support if specifically indicated. All malnourished cancer patients should be considered for nutritional advice and oral supplements in the postoperative period and for a period following discharge.
ARTIFICIAL NUTRITIONAL SUPPORT
Generally, if oral nutrition is not re-established within five to seven days postoperatively, enteral or parenteral feeding should be considered.
ASSESSMENT OF NUTRITIONAL REQUIREMENTS Energy and protein requirements depend on body composition, clinical status and mobility. An estimation of requirements is 30 kcal/kg/day and 1.0 g protein/kg/day for the average patient. Few patients require more than 2,200 kcal/day. Additional calories are unlikely to be used effectively and may constitute a metabolic stress. Daily biochemical monitoring must be undertaken when initially refeeding the chronically severely malnourished patient because of the dangers of hypokalaemia and hypophosphataemia. Nutritional requirements should be determined in consultation with a dietitian. CS Nutritional replacement should be discussed with a dietitian and tailored to the patients requirements.
ENTERAL OR PARENTERAL NUTRITION? Postoperative nutritional support has potentially serious complications. Enteral nutrition uses the physiological route of nutrient intake, is cheaper and is generally safer, and should be the preferred method of nutritional support, in the presence of a functioning gastrointestinal tract. CS Enteral nutrition is the preferred method of postoperative nutritional support and should be used if possible.
Patients with partial gut failure and who are catabolic, eg with necrotising pancreatitis or ongoing intra-abdominal sepsis, may benefit from artificial nutritional support in the postoperative period. In the presence of partial gut function either combined TPN/EN, or if possible, full enteral feeding, is the method of choice. CS For patients with ongoing postoperative complications enteral nutrition should be used whenever possible, combined with parenteral nutrition where necessary, to meet nutritional needs.
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ARTIFICIAL NUTRITIONAL TECHNIQUES
ENTERAL NUTRITION Nasogastric feeding The most appropriate route of enteral tube feeding for patients who require short term support (eg less than four weeks) is via a fine-bore nasogastric tube. Gastrostomy Gastrostomy (endoscopic, radiological or surgical) should be reserved for mid-to long-term feeding. It is more comfortable than nasogastric feeding and has a lower risk of tube misplacement or blockage. Major indications include neurological disorders and head and neck cancer. Contraindications include sepsis, ascites and clotting disorders. Jejunostomy Tubes may be placed surgically or endoscopically. The most common indication is following major upper gastrointestinal surgery. The jejunostomy is sited at the time of surgery and can be used for feeding within 12 hours of surgery. Administration Most surgical patients can tolerate a standard whole protein feed (1 kcal/ml). A peptide or elemental formula can be considered in patients with significant malabsorption. Patients are generally started with 30-50 ml/hour, increasing within 24-48 hours until prescribed targets are reached. If supplementation of an inadequate oral intake is required, then overnight feeding for 8-12 hours may be sufficient and allows the patient to be mobile during the day. A pump should be used to control the rate of feed delivery, avoiding the abdominal cramps and bloating associated with bolus feeding. CS Enteral nutrition should be provided by the simplest technique possible. The feeding should be given in such a way as to interfere minimally with the normal stimuli to eating.
PARENTERAL NUTRITION Peripheral intravenous feeding (eg via a cannula) should only be used in the short term. Central venous feeding, via either a peripherally inserted catheter (PIC line) or a catheter in a central vein, is the preferred route. A dedicated central venous feeding line minimises infective complications. However in suitable circumstances a triple lumen central line inserted under aseptic conditions and with a dedicated port for total parenteral nutrition can be used. Following insertion of a dedicated central or jugular line, a chest X-ray must be taken to exclude a pneumothorax and confirm the position of the catheter tip at or near the junction of the superior vena cava with the right atrium. Mixtures of nutrients are usually combined in a single bag. Many pharmacies now use three or four standard regimens. The solutions contain fixed amounts of energy and nitrogen, and typically provide 1,800-2,400 kcals (50% glucose, 50% lipid) and 10-14 g nitrogen. The amount of electrolytes, vitamins and trace elements can be varied. In general, standard regimens are simpler, safer and cheaper than those prepared individually. CS Parenteral nutrition should be provided through a dedicated intravenous catheter.
MONITORING NUTRITIONAL SUPPORT Nutritional support should be monitored to detect feeding complications and assess the efficacy of the nutritional regimen. The measurements and frequency of monitoring depend on the individual patient, the route and the stage of feeding. Daily monitoring should be carried out in the unstable patient or a patient who has recently started nutritional support (see Table 16).
7 POSTOPERATIVE NUTRITION
Table 16: Monitoring nutritional support requirements Status Biochemistry Fluid balance Nutritional status Nutritional intake CS Markers Electrolytes, urea, blood glucose, urinalysis, liver function tests (twice weekly) Fluid charts, weight Weight, nitrogen balance (once weekly) Nursing records, food and fluid charts
Nutritional and metabolic status should be assessed regularly and the nutritional prescription modified as necessary.
NUTRITION TEAMS A coordinated multidisciplinary team approach to nutritional support can reduce the incidence of feeding complications and improve the overall quality of care. CS Quality of nutritional support is enhanced by the use of dedicated nutrition teams.
POSTOPERATIVE MANAGEMENT IN ADULTS
Information for discussion with patients and carers
EXAMPLE INFORMATION SHEET FOR DISCUSSION WITH PATIENTS
WHO WILL BE LOOKING AFTER YOU? During your stay in hospital you will be cared for by a team of healthcare professionals, including, doctors, nurses, physiotherapists, pharmacists and occupational therapists. Decisions on your care will be made on a team basis with input from all members under the supervision of the consultants who are responsible for your care. The main aim of the team caring for you is to ensure that your recovery from surgery is uneventful and completed in the shortest time possible. Before your operation you will be carefully assessed and this may reveal other conditions requiring treatment. If so you may be started on new treatments which may have to be continued after the operation. WHAT HAPPENS AFTER YOUR OPERATION? Immediately after the operation your recovery from the anaesthetic and surgery will be assessed by measuring your blood pressure, pulse rate, breathing rate, temperature and the amount of oxygen in your blood. If you have had major surgery or have other conditions such as heart disease you may require additional tests. When your condition is stable you will be transferred from the recovery area to a ward, high dependency unit or intensive care unit depending on the type of care you require. If you are taken to an intensive care unit or high dependency unit at first, then as your condition improves and you require less intensive observation, you may then be cared for in a normal ward. In the early phase of your recovery from your operation you may need to be very carefully monitored, especially if you have undergone major surgery. You may find that you are assessed quite frequently, and although you may find this disruptive, it is necessary to monitor your progress. The observations will be no more frequent than necessary to ensure your well being. The monitoring is vital to detect any changes so that remedial actions may be taken at an early stage. You may need oxygen treatment, usually from a mask or a tube in your nose, after your operation. If you have chest or heart problems, this may be needed for several days. In some cases, a tube (catheter) in your bladder will be used to measure how much urine is being produced, which helps show how well the kidneys are working. Your care can also involve treatment to prevent blood clots (deep vein thrombosis), infections, and nausea. COPING WITH PAIN Many patients are concerned about having pain following surgery and your team of carers will have a plan of how this will be controlled. It is important that you tell them if you have pain as they wish to make your recovery as pain free as possible. MOVING AND EATING AFTER YOUR OPERATION Following your operation you will be encouraged to become as mobile as possible as this helps to prevent complications such as blood clots or chest infection and speeds recovery. You may receive instruction from the physiotherapist to help you with your breathing. You will also be encouraged to eat and drink as soon as it is feasible as maintaining your level of nutrition is an important aspect of recovery.
9 DEVELOPMENT OF THE GUIDELINE
Development of the guideline
This guideline was supported by a grant from the Chief Scientists Office which aimed to assess the feasibility of applying formal consensus techniques to SIGN guideline development. Although intended to be fully developed by consensus techniques, the guideline is in fact a hybrid of consensus and evidence based methodology. This situation arose when it became clear that several of the clinical issues which were chosen for inclusion in this guideline were supported by a robust evidence base and these were fed through the standard SIGN development process as described in section 9.3. Following the systematic review of evidence, formal consensus was then applied to statements developed by specialist subgroups of the development group as described in section 9.4. Further details about SIGNs standard evidence based methodology are contained in SIGN 50: A guideline developers handbook available at www.sign.ac.uk
THE DEVELOPMENT GROUP
Dr Harry McFarlane (Co-chair) Mr Robert C Smith (Co-chair) Ms Sarah Armstrong Mr Ian Currie Dr Gordon Drummond Professor Kenneth Fearon Miss Mary Glasgow Dr Graham Hilditch Mr Roland Ingram Dr Simon Mackenzie Ms Morag Naysmith Dr David ONeill Mr Christopher Rodger Professor D Gwyn Seymour Miss Gail Thomson Consultant Anaesthetist, Aberdeen Royal Infirmary Consultant in General Surgery, Falkirk and District Royal Infirmary Associate Director of Nursing, Forth Valley NHS Acute Hospital, Falkirk Clinical Lecturer in Surgery, Royal Infirmary of Edinburgh Consultant Anaesthetist, Royal Infirmary of Edinburgh Professor of Surgical Oncology, Royal Infirmary of Edinburgh Clinical Nurse Educator, Aberdeen Royal Infirmary Specialist Registrar in Anaesthesia, Glasgow Western Infirmary Consultant Orthopaedic Surgeon, Glasgow Royal Infirmary Consultant Anaesthetist, Royal Infirmary of Edinburgh Principal Pharmacist, Western General Hospital, Edinburgh Consultant Physician, Crosshouse Hospital, Kilmarnock Research Fellow, Department of Coloproctology, Glasgow Royal Infirmary Professor of Medicine (Care of the Elderly), University of Aberdeen Senior 1 Physiotherapist, Royal Infirmary of Edinburgh
Miss Gemma Healy Dr Moray Nairn Dr Safia Qureshi Assistant Information Officer, SIGN Programme Manager, SIGN Programme Director, SIGN
Dr Joris Berwaerts Mr Ross Carter Mrs Jane McCready Medicines Control Agency, London Consultant General Surgeon, Glasgow Royal Infirmary Senior Staff Nurse, Victoria Infirmary, Glasgow
SYSTEMATIC LITERATURE REVIEW
The evidence base for this guideline was synthesised in accordance with SIGN methodology. A systematic review of the literature was conducted using an explicit search strategy devised by a SIGN Information Officer in collaboration with members of the development group. Internet searches were conducted on the websites of the US National Guidelines Clearinghouse, the 45
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Canadian Practice Guidelines Infobase, the Australian National Health and Medical Research Council, the New Zealand Guidelines programme, and the UK Health Technology Assessment programme. Searches were also conducted on the search engines Citeline, Medical World Search, Echidna, Medisearch and Google, and all suitable links followed up. Database searches were conducted from 1993-2001 on the Cochrane Library, Medline, Embase and CINAHL. The Medline version of the main search strategies is available on the SIGN website, in the section covering supplementary guideline material. The main searches were supplemented by literature identified by individual members of the development group. All selected papers were appraised using standard methodological checklists before conclusions were considered as evidence.
Nominal group technique (NGT)132 was used to identify 125 items important to the management of postoperative patients. Two further rounds of NGT reduced this list to 14 items which related to clinical assessment and monitoring, or cardiovascular; respiratory; fluid, electrolyte and renal or sepsis management. The items were used to develop a set of key questions, and used to develop the search strategy which forms the basis of the evidence based arm of the methodology (see section 9.3). The systematic review allowed the group to identify evidence gaps, that is, key questions that could not be answered using published evidence. For each of these questions a consensus statement was prepared. The group reviewed the consensus statements and summaries of appraised evidence and rated privately all consensus statements using a 9-point scale where:3 9 = extremely appropriate 5 = uncertain 1= extremely inappropriate The group also listed all changes they would make to the consensus statement, based on both their interpretations of the literature review and their clinical experience. An appropriateness score was calculated, which reflected the panels collective opinion on the suitability of each consensus statement. The appropriateness score for an individual statement is the median of the panels ratings. The panel is considered to be:
n n n
in agreement over the appropriateness of a statement when no more than 3 of the individual members ratings are outside a 3-point region that includes the median rating disagreement occurs when 1 or more ratings is in the 1-3 region, and 1 or more in the 7-9 region clearly appropriate statements will have a median of 7-9 without disagreement clearly inappropriate statements will have a median of 1-3 without disagreement equivocal statements - with a median of 4-6, or where there is disagreement on a proper rating
Only clearly appropriate consensus statements, with a median score of 7-9, are used as consensus statements in this guideline.
CONSULTATION AND PEER REVIEW
NATIONAL OPEN MEETING A national open meeting is the main consultative phase of SIGN guideline development, at which the guideline development group presents their draft recommendations for the first time. A national open meeting for this report was held on 29th October 2002. The draft was also available on the SIGN website for a limited period to allow those unable to attend the meeting to contribute to the development of the guideline.
9 DEVELOPMENT OF THE GUIDELINE
SPECIALIST REVIEWERS The guideline was reviewed in draft form by a panel of independent expert referees. SIGN is very grateful to the following experts: Ms Dorothy Barber Miss Shirley Brennan Dr Martin Cameron Professor Ian Campbell Dr Matthew Checketts Dr Malcolm Daniel Dr Pamela Doherty Dr Dugald Glen Dr Paul Glen Miss Susie Goodwin Mrs Kate Gordon Smith Mr John Graham Mrs Fiona Grant Dr Heather Hosie Mrs Sandra Jamard Mr Richard James Mr Ronald Kennan Ms Caroline MacDonald Mrs Heather Macgowan Dr Fergus Miller Mr Aslam Mohammed Professor Michael Mythen Dr Alastair Nimmo Mr James Parris Dr John Reid Mr Chris Shearer Mr Walter Simpson Dr David Swann Miss Gillian Thain Professor Nigel Webster Miss Senga Welsh Professor Tony Wildsmith Dr John Wilson Nutrition Nurse Specialist, Aberdeen Royal Infirmary Final year medical student, University of Aberdeen Specialist Registrar in Obstetrics and Gynaecology, Aberdeen Maternity Hospital Consultant Physician, Victoria Hospital, Kirkcaldy Consultant Anaesthetist, Ninewells Hospital, Dundee Consultant in Anaesthesia and Intensive Care, Glasgow Royal Infirmary Specialist Registrar in Anaesthesia, Falkirk and District Royal Infirmary Consultant Radiologist, Stirling Royal Infirmary SHOIII / Research fellow, Lister Department of Surgery, Glasgow Final Year Medical Student, University of Aberdeen Practice Development Nurse, Grampian University Hospitals Charge Nurse, Aberdeen Royal Infirmary Practice Development Nurse, Stirling Royal Infirmary Consultant in Anaesthesia, Southern General Hospital, Glasgow Clinical Ward Manager, High Dependency Unit, Stirling Royal Infirmary Final Year Medical Student, University of Aberdeen Consultant in General Surgery, Aberdeen Royal Infirmary Lecturer, School of Nursing and Midwifery, Robert Gordon University, Aberdeen Surgical Co-ordinator, Surgical Unit, Falkirk and District Royal Infirmary Consultant Anaesthetist, Ninewells Hospital, Dundee Specialist Registrar in Orthopaedics, Glasgow Royal Infirmary Portex Professor of Anaesthesia and Critical Care, Institute of Child Health, London Consultant in Anaesthesia, Royal Infirmary of Edinburgh Final Year Medical Student, University of Aberdeen Consultant Radiologist, Borders General Hospital, Roxburghshire Surgical Specialist Registrar, Victoria Infirmary, Glasgow Lay Representative, Glendevon Consultant in Anaesthesia, Royal Infirmary of Edinburgh Clinical Specialist in Respiratory Physiotherapy, Aberdeen Royal Infirmary Professor and Honorary Consultant of Anaesthesia and Intensive Care, Aberdeen Royal Infirmary Charge Nurse, Intensive Care Area, Falkirk and District Royal Infirmary Professor of Anaesthesia, University Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee Clinical Lecturer, Clinical and Surgical Sciences, University of Edinburgh
POSTOPERATIVE MANAGEMENT IN ADULTS
ABC ABG ACC/AHA ADH AF ALI ARDS ASA AVPU BMI CAD CHF CI COPD CS CT ECG FiO2 GCS GI GTN HDU ICD ICU INR IPPB IPPV JVP LBBB LVH MI NG NSAID OR PaCO2 PaO2 PAWCP RCT RR SASM SIGN SIRS SpO2 SaO2 SVA SVT TPN VT Airways, breathing, circulation Arterial blood gases American College of Cardiology/American Heart Association Antidiuretic hormone Atrial fibrillation Acute lung injury Acute respiratory distress syndrome American Society of Anesthesiologists Alert, verbal, painful, unresponsive Body mass index Coronary artery disease Chronic heart failure Confidence intervals Chronic obstructive pulmonary disease Consensus statement Computed tomography Electrocardiogram Fractional concentration of oxygen in inspired gas Glasgow coma score Gastrointestinal Glyceryl trinitrate High dependency unit Implantable cardioverter defibrillators Intensive care unit International normalised ratio (of the prothrombin time) Intermittent positive pressure breathing Intermittent positive pressure ventilation Jugular venous pressure Left bundle branch block Left ventricular hypertrophy Myocardial infarction Nasogastric Non-steroidal anti-inflammatory drug Odds ratio Arterial carbon dioxide partial pressure (measured from a blood gas sample) Arterial oxygen partial pressure (measured from a blood gas sample) Pulmonary artery wedge capillary pressure Randomised controlled trial Relative risk Scottish Audit of Surgical Mortality Scottish Intercollegiate Guidelines Network Systemic inflammatory response syndrome Oxygen saturation measured by a pulse oximeter Oxygen saturation from a blood gas sample Supraventricular arrhythmia Supraventricular tachycardia Total parenteral nutrition Ventricular tachycardia
Annex 1 Assessing Conscious Level
THE AVPU SCALE A - Alert V - Verbal P Painful U - Unresponsive The patient is alert, awake, responsive to voice and oriented to person, time, and place. The patient responds to voice, but is not fully oriented to person, time, or place. The patient does not respond to voice, but does respond to a painful stimulus, eg pinching the skin. The patient is unresponsive to both verbal and painful stimuli.
THE ABBREVIATED MENTAL TEST Correct answers to each question score one point Age Time to nearest hour An address, eg 42 West Street, to be repeated at the end of the test Month Year Name of place Date of birth Year first world war started Name of present monarch Count backwards from 20 to 1 TOTAL SCORE Scores: 8-10 normal; 7 probably abnormal; <6 abnormal THE GLASGOW COMA SCALE AND SCORE Feature Eye opening Scale Responses Spontaneous To speech To pain None Orientated Confused conversation Words (inappropriate) Sounds (incomprehensible) None Obey commands Localise pain Flexion - Normal - Abnormal Extend None Score Notation 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 3/15 - 15/15
Best motor response
TOTAL COMA SCORE
POSTOPERATIVE MANAGEMENT IN ADULTS
Annex 2 American Society of Anesthesiologists Physical Status Classification System
ASA 1 ASA 2 ASA 3 ASA 4 ASA 5 ASA 6 A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain-dead patient whose organs are being removed for donor purposes
Annex 3 Example of a Postoperative Monitoring Chart
This is an example chart only. These parameters will not be suitable for all patients and should be adjusted in line with local protocols.
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CARDIOVASCULAR MANAGEMENT (Contd.)
Postoperative blood pressure should always be reviewed with reference to the preoperative and intraoperative assessments Further assessment is required for patients with: § § heart rate < 50 and > 100 bpm blood pressure <100 mm Hg systolic. Patients in whom there is a suspicion of postoperative pulmonary complications should have an arterial blood gas analysis, a sputum culture and ECG. Chest X-ray should be performed on suspicion of major collapse, effusions, pneumothorax or haemothorax. Other investigations should be used only if there are specific indications. Oxygen should be given to patients with hypoxaemia using a device that is best tolerated to achieve the necessary SpO2. In normally hydrated patients humidification is unnecessary. Failure to maintain an SpO2 >90% or PaO2 >8.0 kPa is an indication to consider assisted ventilation. Patients developing respiratory failure should be referred to a critical care specialist to be assessed for possible assisted ventilation. The referral should be timely as hypoxia or hypercapnia may lead rapidly to cardiorespiratory arrest. Diagnosis of respiratory infection Any two of the following on two or more days: § Pyrexia >380C § Positive sputum culture § Positive clinical findings § Abnormal chest X-ray – Atelectasis/infiltrates
Hand washing with soap and water or with alcoholic cleansing agents should be performed before and after patient contact.
Early identification and appropriate treatment of sepsis improves outcome.
Patients on regular antihypertensive medication should normally be maintained on this medication perioperatively. If the patient becomes hypotensive then it may be appropriate to discontinue some drugs. Beta blockers and IV nitrates may be used safely and effectively in postoperative hypertension. Beta blockers should be continued perioperatively in patients previously taking these drugs for coronary disease, congestive heart failure, hypertension or arrhythmias. Be aware of clinical factors which increase risk to the patient and how these interact with the risks imposed by the surgical procedure. Seek expert help early in the management of serious or potentially serious arrhythmias. Reconsider the level of care. Search for the underlying causes of any supraventricular arrhythmias, eg hypoxia, hypovolaemia, electrolyte abnormality, sepsis or drug toxicity. Where perioperative MI is diagnosed or suspected early specialist medical advice should be sought. Maintain normothermia in the postoperative period.
Urine and blood cultures should be obtained whenever there is reason to suspect systemic sepsis.
If the cause of sepsis is unknown, treat with broad spectrum antibiotics, guided by local protocols.
Results from microbiological specimens should be reviewed regularly and antibiotics changed as necessary.
A course of antimicrobial treatment should generally be limited to 5-7 days. Fungi and atypical organisms can contribute to sepsis syndrome, so take cultures and prescribe appropriately.
Systemic inflammatory response syndrome (SIRS) is defined as the presence of 2 or more of the following: § temperature >380C or <360C § heart rate >90 bpm § respiratory rate >20 breaths/min or PaCO2 <4.3kPa § white cell count >12,000 cells/mm3 , <4,000 cells/mm3 or >10% immature forms.
When SIRS is present an infective cause should be sought first.
FLUID, ELECTROLYTE & RENAL MANAGEMENT
Accurate assessment of fluid and electrolyte status can be difficult and the treatment of a particular patient must be individualised and reviewed frequently in the light of the response to treatment. Volume depletion should be avoided as this can lead to poor perfusion and problems such as anastomotic breakdown, cerebral damage, renal failure and multiple organ failure. Diuretics should not be used to treat oliguria and should be reserved for fluid overload. Hyponatraemia is more commonly due to excess water than sodium deficiency – assess volume status.
ASSESSMENT OF HYPOTENSION
Observe if: Awake or easily rousable Comfortable Normal preoperative BP Warm Well perfused (capillary refill <2 seconds) Heart rate 50-100 bpm Passing urine (>0.5 ml/kg/hr) No obvious bleeding Cold Capillary refill > 2 seconds Heart rate >100 or <50 bpm Oliguric (<0.5 ml/kg/hr) Signs of bleeding (drains, wounds, haematoma) Distressed Hypertensive preoperatively Seek further advice if: Drowsy or unrousable
Oral intake should be commenced as soon as possible after surgery.
Nutritional replacement should be discussed with a dietitian and tailored to the patient's requirements.
Enteral nutrition is the preferred method of postoperative nutritional support and should be used if possible.
Nutritional and metabolic status should be assessed regularly and the nutritional prescription modified as necessary.
Hypernatraemia most commonly indicates a total body deficiency of water and is an indication for prompt assessment and intervention, especially when levels exceed 155 mmol/L. Hypokalaemia can delay postoperative recovery - magnesium supplementation may also be required. Hyperkalaemia is a medical emergency – obtain senior help. Metabolic acidosis is usually due to poor tissue perfusion but can also be caused by excessive administration of saline.
Given the lack of a strong evidence base of effective practice for postoperative management this guideline has been developed using a combination of evidenced based and consensus techniques. Initial systematic searches identified any relevant evidence. The critically appraised evidence, together with the clinical experience of the guideline development group, informed the formal consensus methods that were used to develop recommendations. These are presented in the form of “consensus statements”.
POSTOPERATIVE MANAGEMENT IN ADULTS: A PRACTICAL GUIDE TO POSTOPERATIVE CARE FOR CLINICAL STAFF CHECKLIST FOR FIRST POSTOPERATIVE ASSESSMENT
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Medications Allergies Intraoperative complications Postoperative instructions Recommended treatment & prophylaxis Oxygen saturation
PRINCIPLES OF POSTOPERATIVE MANAGEMENT
Past medical history Optimal postoperative care requires: § § § § § § Only accept responsibility appropriate to your training and experience. If in doubt ASK FOR HELP clinical assessment and monitoring respiratory management cardiovascular management fluid, electrolyte and renal management control of sepsis nutrition
SAMPLE MONITORING REGIMEN FOR FIRST FEW POSTOPERATIVE HOURS
DISCHARGE FROM THEATRE AND POSTANAESTHETIC RECOVERY
Anaesthetic and surgical staff should record the following items in the patient’s case notes: § § § any anaesthetic, surgical or intraoperative complications any specific postoperative instruction concerning possible problems any specific treatment or prophylaxis required (eg fluids, nutrition, antibiotics, analgesia, anti-emetics, thromboprophylaxis).
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Effort of breathing/use of accessory muscles Respiratory rate Trachea central or not? Symmetry of respiration/expansion Breath sounds Percussion note Hands - warm or cool, pink or pale?
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Capillary return <2s or not? Pulse rate, volume and rhythm Blood pressure Conjunctival pallor Jugular venous pressure Urine colour and rate of production Drainage from drains, wounds & NG tubes Patient conscious and normally responsive ? (AVPU; Alert, Verbal, Painful, Unresponsive)
THE FIRST POSTOPERATIVE ASSESSMENT
A postoperative assessment should be carried out when the patient returns from theatre. Patients at risk of deterioration require frequent assessment. Patients with the following risk factors for deterioration should be reassessed within two hours of the first postoperative assessment: § ASA grade ≥ 3 § emergency or high risk surgery § operation out of hours The doctor completing the initial postoperative assessment should consider the monitoring regimen and appropriate level of care required for the next 24 hours in collaboration with the nursing team.
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If abnormal determine: § if confusion is present (AMT) § GCS, oxygen saturation and blood glucose
Any significant symptoms eg chest pain, breathlessness Pain and adequacy of pain control Following specialist surgery it may be necessary to assess additional factors.
Patients requiring the frequent monitoring of multiple variables should be considered for care at level 2 or above.
Trends in the physiological data, rather than absolute numbers, should be reported to assist in the detection of deteriorating patients before a severe physiological compromise occurs.
Postoperative monitoring should be continued on a daily basis.
The monitoring regimen should be reviewed daily so as best to provide data for clinical decision making.
Any change in a monitoring regimen should prompt reassessment of the level of care.